Trucking - ALL Owner*Cynthia F. - CynthiaF@CondonMeek.comJeremiah F. - Jeremiah@meekagency.comTrace M. - Trace@CondonMeek.comTruckingDate Date Format: MM slash DD slash YYYY DOT#FMCSA Insurance Web InfoSafer Web InfoEffective Date Date Format: MM slash DD slash YYYY Company NameOwner Name First Last Is the Owner also a Driver? Yes No Company InfoFEIN #Business Start DateDescriptions of OperationsCommodities Hauled and PercentagePhoneEmail Garaging AddressAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Garaging Address the same as Mailing? Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Radius of OperationsHave you been Cancelled or Non-Renewed in the Past 3 yearsYes (see Notes)NoNumber of Drivers (Do not Include Owner) 1 2 3 4 Number of Trucks (Do Not Include Owner) 1 2 3 4 Number of Trailers (Do Not Include Owner) 1 2 3 4 Driver 1Name First Last Date Hired# of Years with a CLDOBDriver License NumberLicense StateDriver 2Name First Last Date Hired# of Years with a CLDOBDriver License NumberLicense StateDriver 3Name First Last Date Hired# of Years with a CLDOBDriver License NumberLicense StateDriver 4Name First Last Date HiredDOB# of Years with a CLDriver License NumberLicense StateTruck 1Type:TractorTruckBox TruckStraight TruckTow TruckVIN:Year, Make and ModelTypeStated ValueTruck 2Type:TractorTruckBox TruckStraight TruckTow TruckVIN:Year, Make and ModelTypeStated ValueTruck 3Type:TractorTruckBox TruckStraight TruckTow TruckVIN:Year, Make and ModelTypeStated ValueTruck 4Type:TractorTruckBox TruckStraight TruckTow TruckVIN:Year, Make and ModelTypeStated ValueTrailer 1TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN #Year, Make and ModelTypeStated ValueTrailer 2TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN #Year, Make and ModelTypeStated ValueTrailer 3TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN #Year, Make and ModelTypeStated ValueTrailer 4TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN #Year, Make and ModelTypeStated ValueLiabilityLiability Limit750,0001,000,000OtherTrailer Interchange ? YES NO CargoCargo LimitCargo Deductible5001,0002,5005,000OtherReferYESNOHow did you hear about us? Google Mailer Cold Call Facebook Texting Newsletter Other Send to Missy Bonds?*YESNOWho do you want Missy Bonds to quote with?* Select All Progressive Berkshire Fill out QQ form and email back Notes