Quick Quote Burt James bjames@fleetriskmgt.com PO Box 21860 Saint Simons Island, GA 31522 Phone: (866) 638-8277 Fax: (866) 589-9756 Business Owner: Email: MC#: Business Name: DOT#: Federal ID#: Address: City: State: Zip Code: If Business Address is different from Mailing Address include Mailing Address in the Following: Address: City: State: Zip Code: Phone:Cell:Fax:Year in Business: Truck and Trailer Information*YearMakeTypeVIN#Value Tractor (CT)Box Truck (S)DuallyDry Van (VST)Reefer (RST)Flatbed (FST)Low Boy (BST)Grain Hopper (HST)Auto Transport (ATT)End-Dump (DST)Belly Dump (BDT)Side Dump (TSD)Misc. Tanker (MST)Stainless Steel (SST)Insulated Tank (ITT)Pneumatic (PST)Gasoline (GST)Compressed Gas (CST)Gooseneck (GNT)Logging (LOG)Pick UpCargo VanDump Truck - Dual AxleDump Truck - Tri Axle Driver Information:*Class A CDL - 2 Years Experience MinimumNameDOBLicense #StateYears of ExperienceDate of Hire AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMN MOMSMT NCNDNENHNJNM NVNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY * Please see attached form for additional Drivers and EquipmentCurrent Carrier Commodities HauledCommodity%Value Insurance Claims in the Past 3 YearsTypeAmount Paid CoverageLiabilityPhysical DamageCargoGeneral LiabilityTrailer InterchangeNon-Owned Trailer$750,000$1000,000-$1,000 Ded.$2,500 Ded.-$50,000$100,000$150,000$200,000$250,000-YesNo-$15,000$20,000$25,000$30,000$40,000$50,000-$15,000$20,000$25,000$30,000$40,000$50,000-Average Run: Max Run: Effective Date: Current Premium: What are your regular routes? Which major cities do you enter? Additional Drivers and EquipmentTruck and Trailer InformationYearMakeTypeVIN#Value Tractor (CT)Box Truck (S)DuallyDry Van (VST)Reefer (RST)Flatbed (FST)Low Boy (BST)Grain Hopper (HST)Auto Transport (ATT)End-Dump (DST)Belly Dump (BDT)Side Dump (TSD)Misc. Tanker (MST)Stainless Steel (SST)Insulated Tank (ITT)Pneumatic (PST)Gasoline (GST)Compressed Gas (CST)Gooseneck (GNT)Logging (LOG)Pick UpCargo VanDump Truck - Dual AxleDump Truck - Tri Axle Loss Payee InformationBank NameAddressFax or Email AddressLast 4 Digits of VIN Driver Information: Class A CDL - 2 Years Experience MinimumNameDOBLicense #StateYears of ExperienceDate of Hire AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMN MOMSMT NCNDNENHNJNM NVNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY Summary & NotesCAPTCHA Δ