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P.O. Box 1224          141 East Central Ave

2625 South Broadway                   Suite 420

Salem, IL 62881           Winter Haven, FL 33880

800-358-3073 (Office)         877-908-6837 (Office)

618-548-9021 (Fax)             863-292-2214 (Fax)

Please complete the form below and one of our associates will contact you as soon as possible.

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Name	Address
Company	City
E-mail	State Zip
Phone	FAX

Social Security or Federal Tax #
Operation	Dealer Transporter Installer (Check All That Apply)

Individual Partnership Corporation LLC

Current Insurance Company

Renewal Date

Liability Coverage

$ Cargo $

General Liability(if needed)

$ If so... # of Employees

Vehicles

1.	Year Make Model VIN Phy. Damage

2.	Year Make Model VIN Phy. Damage

3.	Year Make Model VIN Phy. Damage

4.	Year Make Model VIN Phy. Damage

Drivers

1.	Name DOB DL Accident in last 3 yrs

2.	Name DOB DL Accident in last 3 yrs

3.	Name DOB DL Accident in last 3 yrs

4.	Name DOB DL Accident in last 3 yrs

5.	Name DOB DL Accident in last 3 yrs

Any drivers with less than 2 years CDL experience?

State or Federal Filings Required?

Radius of Operation?

ICC#

DOT# Number of years in operation?

Comments (Additional Equipment):

Send mail to deburdin@precisiontrucks.com with questions or comments about this web site. Copyright © 2006 Precision Insurance & Financial Services, Inc Last modified: 10/19/06

Send mail to deburdin@precisiontrucks.com with questions or comments about this web site.
Copyright © 2006 Precision Insurance & Financial Services, Inc
Last modified: 10/19/06