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SANBORN, IOWA          ●          SHELDON, IOWA
 

 

 

 

 

 

Trucking Specialists
For specific questions about farm insurance -- contact:

 

Jim Jansen

Sanborn Office

800-831-8545

E-mail

 

or

 

Dave Van Essen

Sanborn Office

800-831-8545

E-mail

 

 

 

 

 

 

 

 

 

 

Please provide the information below & we will contact you shortly with a quote.

 

* = Required

Company Name

 *

Address

 *

City

 *

State

 *

Zip

*

Phone

*

Contact Person

 *

Policy Expiration Date

 *

Radius

 *

Commodities Hauled

 *

TRACTOR/TRUCK INFORMATION *

TRACTOR

VALUE
1.

$
2.

$
3.

$
4.

$
5.

$
6.

$
7.

$
8.

$
9.

$
10.

$
     

TRAILER INFORMATION *

TRAILER

VALUE
1.

$
2.

$
3.

$
4.

$
5.

$
6.

$
7.

$
8.

$
9.

$
10.

$
     

DRIVERS INFORMATION *
1. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
2. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
3. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
4. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
5. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
6. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
7. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
8. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
9. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 
10. NAME     D.O.B.    
  LIC. #      S.S. #     
  YRS. EXP          
 

Present Insurance Co.

 *

Losses in Past 3 Years

 *

Carrier #

 *

Federal Tax ID #

 *

Work Comp Payroll

 *

Liability Limits

 $  750,000

$1,000,000

 

Cargo Limits

 *

Physical Damage Deductible

 $ 500

$1,000

$2,500

$5,000

 

Cargo Deductible

 $  500

$1,000

      

 

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