| Customer Information (* = required field) |
| *Company Name |
|
| Is this a Multiple Location
Client? |
(check if Yes) |
| *Client Contact Name (First) |
|
| *(Last) |
|
| *Client Contact Title |
|
| *Client Contact Phone Number |
|
| Client Contact Email or Fax |
|
| Street/Mailing Address |
|
| City |
|
| State or Province |
|
| Zip or Postal Code |
|
| Approximate Number of Vehicles |
|
Vehicles to Be Enrolled
Please send us a current listing of vehicles indicating which
ones are to receive decals. We will contact you to confirm
the best match of decal sizes to fit each type of vehicle. You
may send the vehicle list by email or fax.
|
| Insurance
Information |
| Insurance Agent/Broker |
|
| Agent/Broker Contact Person |
|
| Insurance Carrier |
|
| Branch/Field Office Name |
|
*Policy Number (required if
billing insurance carrier) |
|
*Policy expiration Date (required
if billing insurance carrier) |
|
| Underwriting Contact Person |
|
| Underwriting Phone Number |
|
| Underwriting Email Address |
|
| Loss Control Contact Person |
|
| Loss Control Phone Number |
|
| Loss Control Email Address |
|
Add any additional comments
below:
|
|
|
