General Information     Company Name       Type of Business Social Security/Tax ID # Date of Birth   Individual Proprietership Partnership Corporation Other             MC or DOT Number         (If you have your own authority)   Contact Person     Company Address     City State (call for information on states not listed)    -- Select State -- Arkansas Florida Georgia Illinois Indiana Louisiana Kentucky Missouri North Carolina Ohio Tennessee Virginia West Virginia   ZIP/Postal Code Email       Phone Number Fax Number                Preferred method of contact.       Phone Email Fax Postal Mail          Insurance Information               I haul under my own authority or need my own primary liability       I am an Owner/Operator and haul under someone else's authority       I do not have Federal Authority and only need State Filings               Account Size (power units) Current Insurance Expiration Date       1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20       Specific Commodities Hauled             Major Cities Traveled Through             Limits of Liability Needed Cargo Limits Needed       $750,000 $1,000,000 $2,000,000 Other $50,000 $100,000 $250,000 Other       Physical Damage Coverage Required       Yes No       Years in Trucking Years with own Insurance                 Radius Traveled       0-300 Miles           300-1000 Miles           Over 1000 Miles         Current auto liability insurance company (if applicable)             Auto liability company for previous year (if applicable)             Any accidents or losses in the past three years?       No Yes       If you answered "Yes" to the above question, please describe in detail         Please provide any additional information about your company that may be helpful.            Driver Information        Name  Driver License #  DL State  Age Years Exp.  Date Hired          Equipment Information (List all trucks, tractors and trailers)       Year  Make  Model  VIN                 Please enter the security code as shown:               If you have more drivers or equipment than this form allows, please call our office at 1-800-343-6584 for assistance.
Raymond Nelson Insurance Agency, Inc. 1102 East 21st Street • P.O. Box 522 • Hopkinsville, KY 42240 (270) 885-1800 • (800) 343-6584 • Fax: (270) 885-6534 Site Developed by Zool Computing