RJS Insurance Services


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Your Last Name
Your First Name
Email Address
Business Name or Corporate Name
Year(s) in business
Year(s) with Commercial Insurance
ICC/MC#
CA#
Mailing Address
City
State, Zip Code
Phone
Fax
Garage Address
City
State, Zip Code
Radius of Operation
Maximum Radius of Operation
Annual Milleage

Auto Liability Limit:

Commodities (Cargo) Transported
(include percentage of each in right hand column)

Commodity(cargo)	%
Commodity(cargo)	%
Commodity(cargo)	%
Commodity(cargo)	%

Cargo Limit:

	Year	Make	# of Axles	Vehicle Type	GVW	Actual Cash Value
1						$.00
2						$.00
3						$.00
4						$.00
5						$.00
6						$.00


	Name	License #	D.O.B.	# of Accidents	# of Violations
1
2
3
4
5
6


	Effective From / To	Carrier	Policy #	Claims in Dollar Amount
1				$.00
2				$.00
3				$.00
4				$.00
5				$.00
6				$.00


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© 2007 RJS Insurance Services Inc. Insurance License # OB01328
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