Independent Truckers To receive a quote, please complete and SUBMIT this form. *INDICATES REQUIRED FIELD APPLICANT'S NAME * EMAIL PHONE NUMBER * TRUCKING COMPANY NAME OWNER'S NAME * TYPE OF COMPANY * Sole ProprietorLimited Partnership (LLP)Limited Liability Company (LLC)Corporation (INC) STATE OF INCORPORATION (IF APPLICABLE) NUMBER OF TRUCKS OPERATED DESCRIPTION OF TRUCK(S) STATES TRUCKS ARE TAGGED MarylandVirginiaPennsylvaniaWashington DCOther DOES COMPANY AND DRIVERS HAVE GOVERNMENT SECURITY CLEARANCE? YesNo IS COMPANY REGISTERED AS: Small BusinessMinority-OwnedWoman-Owned REGISTERED WHERE? PHYSICAL ADDRESS STREET ADDRESS * ADDRESS LINE 2 City * State * Zip Code * DIFFERENT MAILING ADDRESS? YesNo MAILING ADDRESS (IF APPLICABLE) OFFICE PHONE OFFICE FAX CELL PHONE HAULING CONTACT HAULING EMAIL HAULING PHONE BILLING CONTACT BILLING EMAIL BILLING PHONE INSURANCE COMPANY INSURANCE AGENT AGENT EMAIL AGENT PHONE ADDITIONAL COMMENTS * UPLOAD COPY OF REGISTRATION UPLOAD COPY OF INSURANCE CERTIFICATE
