Trucking - ALL Owner* Cynthia F. - CynthiaF@CondonMeek.com Jeremiah F. - Jeremiah@meekagency.com Trace M. - Trace@CondonMeek.com TruckingDate MM slash DD slash YYYY DOT# FMCSA Insurance Web Info Safer Web Info Effective Date MM slash DD slash YYYY Company Name Owner Name First Last Is the Owner also a Driver? Yes No Company InfoFEIN # Business Start Date Descriptions of Operations Commodities 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 Operations Have you been Cancelled or Non-Renewed in the Past 3 years Yes (see Notes) No Number 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 CL DOB Driver License Number License State Driver 2Name First Last Date Hired # of Years with a CL DOB Driver License Number License State Driver 3Name First Last Date Hired # of Years with a CL DOB Driver License Number License State Driver 4Name First Last Date Hired DOB # of Years with a CL Driver License Number License State Truck 1Type:TractorTruckBox TruckStraight TruckTow TruckVIN: Year, Make and Model Type Stated Value Truck 2Type:TractorTruckBox TruckStraight TruckTow TruckVIN: Year, Make and Model Type Stated Value Truck 3Type:TractorTruckBox TruckStraight TruckTow TruckVIN: Year, Make and Model Type Stated Value Truck 4Type:TractorTruckBox TruckStraight TruckTow TruckVIN: Year, Make and Model Type Stated Value Trailer 1TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN # Year, Make and Model Type Stated Value Trailer 2TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN # Year, Make and Model Type Stated Value Trailer 3TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN # Year, Make and Model Type Stated Value Trailer 4TypeDry VanReeferFlatbedGoose-neckAuto HaulerVIN # Year, Make and Model Type Stated Value LiabilityLiability Limit 750,000 1,000,000 Other Trailer Interchange ? YES NO CargoCargo Limit Cargo Deductible 500 1,000 2,500 5,000 Other Refer YES NO How did you hear about us? Google Mailer Cold Call Facebook Texting Newsletter Other Send to Missy Bonds?* YES NO Who do you want Missy Bonds to quote with?* Select All Progressive Berkshire Fill out QQ form and email back Notes