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Bergkamp Insurance Center, Inc.
Fast Quote Insurance Form

Print and fax this form to 620-662-8966

Name: _________________________________________
Phone: _________________________________________

Street:

_________________________________________
City, State, ZipCode: _________________________________________
Email: _________________________________________

Present insurance company: __________________________________
Date present insurance expires: __________________________________

If you are filed with the Federal highway department, please give your MC#: ___________

Owner/Operator? _____Yes ; _____No Years as Owner/Operator? ___________
Fleet Owner? _____Yes ; _____No Radius? ___________
Hired Drivers? _____Yes ; _____No    

Do you haul hazardous material? _____Yes ; _____No
 

Big cities travelled:







Commodities hauled:



Tractor Year:______ Make:______ Value:______ Trailor Year:______ Make:______ Value:______
Tractor Year:______ Make:______ Value:______ Trailor Year:______ Make:______ Value:______
Tractor Year:______ Make:______ Value:______ Trailor Year:______ Make:______ Value:______
Tractor Year:______ Make:______ Value:______ Trailor Year:______ Make:______ Value:______

Please send me information on: ____Collision, Fire, Theft, CAD
  ____Non-Trucking Liability
  ____Full Liability
  ____Cargo

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