Name: Karen & King Insurance
Address: 5051 Peachtree Corners Cir, Norcross, GA, 30092, US
Telephone: (404) 918-1459

GENERAL INFORMATION
Type*
- NEW BUSINESS
- ESTABLISHED
BUSINESS NAME*
Contact Email*
DBA NAME
US DOT #*
TAX ID #*
MC #*
DATE REQUIRED*
MM slash DD slash YYYY
EFFECTIVE DATE*
MM slash DD slash YYYY
YEARS IN BUSINESS*
MAILING ADDRESS*
Street Address City State ZIP Code
PHYSICAL ADDRESS*
Street Address City State ZIP Code
CONTACT NAME*
DOB*
MM slash DD slash YYYY
YEARS EXP*
EMAIL*
PHONE*
FAX
COVERAGES, LIMITS, DEDUCTIBLES, ADDITIONAL COVERAGES REQUESTED (CHECK ALL THAT APPLY)
COVERAGE*
- AUTO LIABILITY
- PHYSICAL DAMAGE
- MOTOR TRUCK CARGO
- GENERAL LIABILITY
- TRAILER INTERCHANGE
- NON-OWNED PHYS
- EXCESS/UMBRELLA
- BOBTAIL coverage

LIST LIMIT & DEDUCTIBLE FOR EACH COVERAGE CHOSEN*

COVERAGE	LIMIT	DEDUCTIBLE

PERCENTAGE*

0-50 MI.	50-200 MI.	200-500 MI.	500+ MI.

COMMODITIES HAULED*

COMMODITY DESCRIPTION:	% HAULED	AVG. LOAD $	MAX LOAD $:	SHIPPER

EQUIPMENT LIST - TRACTORS*

YEAR	MAKE	VIN #	TYPE	VALUE ($)	LOSS PAYEE

EQUIPMENT LIST - TRAILERS*

YEAR	MAKE	VIN #	TYPE	VALUE ($)	LOSS PAYEE

DRIVERS LIST*

NAME	DRIVER LICENSE #	STATE	DOB	DOH	YRS EXP

Commercial Trucking Quote Request

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