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America one Insurance Service Inc.

License No: 6012066

TRUCK INSURANCE ONLINE FORM SUBMISSION

Company Name
Owner
E-mail
D.O.B
Does owner have CDL License?
Loss Payees/Lease?
Contact Person
Contact Phone Number*
Address
Garage Address (Leave blank if same as above)

Please remember to click Save/Add to add driver,vehicle and trailer information to the form. By not clicking the Save/Add button, your agent will not receive the information!

List Drivers
Full Name
Vehicle Information*
Trailer Information

Description of Operations

Business Type
Year Established?
Business Operations*
Years Experience
Radius of Operations
Is this a New Venture?*
When was this Business established?*
If tow truck operation, do you do repos?
Do you Operate in more than one State?*
Do you haul hazardous material
Do you operate on a regular route?
Do you rent/lease your vehicles to others?
Do you hire any vehicles?

Type of Insurance Requested

Currently Insured?

Please submit any and all Declaration pages/Loss Runs/Logs/motorvehicle records to info@americaone-ins.com

Desired Deductible
Cargo Coverage?
Do you haul for hire?*
List type of cargo hauled*
Amount of Liability Coverage Required*
Do you need a General Liability Policy?*
Physical Damage coverage?*
Do you need workers comp?
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