DATA COLLECTION FORM

REQUIRED FIELDS    Required Item

FOR ASSISTANCE WITH THIS PROCESS PLEASE CONTACT OUR SERVICE CENTER:

INSUREDTRUCK, LLC
121 Civic Center Drive ~ Suite 210
Lake Saint Louis, MO 63367
VOICE: (636)443-3050
E-MAIL:www.INSUREDTRUCK.com

INSURANCE AGENCY INFORMATION
Required Item    Email Address
Web Site Address - http://
Required Item    Enter Your Agency Contact Information.
Ageny Name, Agency Address,
Agency Phone / Fax Numbers, Name of Agent.
(The ABOVE will become part of our Notification System)
 
TRUCKING COMPANY INFORMATION:
Email Address
Web Site Address - http://
Required Item     TRUCKING COMPANY NAME
Required Item     TRUCKING COMPANY ADDRESS
Required Item    TRUCKING COMPANY CITY
Required Item    TRUCKING COMPANY STATE
Required Item     TRUCKING COMPANY ZIP CODE
Required Item     TRUCKING COMPANY CONTACT PERSON
INSURED UNITS SECTION
Required Item    COMPANY MC# / DOT#
Required Item    POLICY NUMBER
Required Item    POLICY LIMIT
Required Item    POLICY EXPIRATION DATE
Required Item    NUMBER OF UNITS INSURED
UNIT DESCRIPTIONS
Required ItemUNIT 1 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 2 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 3 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 4 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 5 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 6 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 7 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 8 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 9 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
Required ItemUNIT 10 ~ ENTER YEAR / MODEL /VIN# or SERIAL#
To SUBMIT more than 10 units ~ Check this box.
Please SUBMIT and then CLEAR the form and enter the ADDITIONAL UNITS / SUBMIT again.
For assistance with this process please contact our SERVICE CENTER
 
    
THANK YOU ~ © 2007 Dynamic Management Solutions of Missouri, LLC