Transcription of Transportation quick quote form - Graham-Rogers, …
1 VEHICLE INFORMATIONYEARCOVERAGE & LIMITSDEDUCTIBLECARGO MAKETRAILER TYPEGVWVIN # PREVIOUS CARRIER & LOSS INFORMATION - MUST SHOW CURRENT YEAR AND PREVIOUS 2 YEARS. IF PREVIOUSLY LEASED TO ANOTHER COMPANY, LIST THAT _____OTHER THAN COLLISION _____ COMMODITY % OF TOTAL VALUE PER TRUCK LOAD TRANSPORTED REVENUE MAXIMUM AVERAGE AGENCY INFORMATION AGENCY INFORMATIONINSURED INFORMATIONINSURED NAME1. US DOT #* _____2. IS THERE BROKER AUTHORITY UNDER THIS FMCSA #? NO YES (MC # )3. COMMODITIES HAULED_____ 4. STATES ENTERED_____ 5. MAJOR CITIES_____ 6. HAS RISK BEEN CANCELLED OR NON-RENEWED IN LAST 3 YEARS? YES NO7. IS RISK COVERED BY WORKERS' COMPENSATION? YES NO8. HOW MANY YEARS HAS INSURED OWNED COMMERCIAL EQUIPMENT?9. FILINGS NEEDED? YES NO (IF YES, FMCSA DOCKET # )10. OWNER S NAME_____ OWNER S SSN:_____ 11. DO YOU PULL: DOUBLES TRIPLES BOTH NEITHER12.
2 DO YOU ALLOW NON-EMPLOYEE PASSENGERS? YES NO quick QuoteTransportation DepartmentPhone: (800) 456-8123 Fax: (918) 336-4842 Graham-Rogers, In DEDUCTIBLE(S)_____CARGO DEDUCTIBLE(S)CARGO LIMIT_____PRIOR CARRIERRADIUS (MILES)PRESENT VALUENAMEDATE OF BIRTHLICENSE NUMBERSTATEHIRED# YRS COMM LDRIVING 3 YRS - # OFMOV. VIOLATIONS ACCIDENTS LIABILITY PRIMARY LIABILITY or NON-TRUCKING LIABILITY AUTO LIABILITY LIMIT _____UNINSURED MOTORIST LIMIT _____UNDERINSURED MOTORIST LIMIT _____MEDICAL PAYMENTS _____HIRED AUTO Liab _____ Phys Dmg _____ Cargo _____ NON-OWNED AUTO(S)_____ # OF EMPLOYEES_____ TRAILER INTERCHANGE(UIIA AGREEMENT REQUIRED) _____OTHER ( _____) _____(SELECT ONE) PHYSICAL DAMAGESPECIFIED CAUSES OF LOSS & COLLISION COMPREHENSIVE & COLLISION POLICY DATESCOMPANY NAME or PREVIOUS LESSEE NAMEPOLICY NUMBERSPREMIUM AMOUNT# OF CLAIMSTOTAL PAID & RESERVEDAGENT CODEAGENCY NAMECITY STATECONTACT NAME PHONE FAX EMAILGARAGING ADDRESSPHYSICAL ADDRESSCITY STATE ZIPDESIRED EFFECTIVE DATE# OF YEARS PRIMARY LIABILITY COVERAGE UNDER ABOVE NAMEIF NON-TRUCKING LIABILITY, NAME OF COMPANY LEASED TO
