loss-runs-release

Company name*

Company contact name*

Email*

Phone*

DOT #*

MC #

Garaging address of units

Commodities hauled by company

Year DOT/business started

Drivers information *

Truck and trailer information *

Radius miles of operations

Cargo limit amount

Do you need trailer interchange?

YesNo

BOX for amount of coverage

Do you require General Liability coverage?

YesNo

Do you require reefer coverage?

YesNo

Would you like Patrick McNealis Insurance and Financial Group to acquire your companies Loss Runs? (Loss Runs show if you have had any claims, accidents, etc.) By answering “yes” below, you will sign a release form, (a electronic signature box will pop up), so we can gather all Loss Runs from your Insurance Carriers, up to 5 years. This will save you time by having our Insurance Agency gather them for you. We will use the Loss Runs during the quoting process.

Click Here to Sign

Owner's Name*

Owner Signature*

By agreeing to the following submission, you are allowing Patrick McNealis Insurance and Financial Group Inc (PMM Services Inc.) herein referred to as: “Agency” to obtain up to 5 years of current valued Loss Runs from your current or past Carrier(s). We are committed to the protection of privacy and any information gathered, and information gathered and used would be within the scope of the agreement of the “insured business” seeking the services of the agency to solicit a quote(s) from Insurance Carriers. Any other private information collected on the business, drivers, etc. would be utilized for the same. Our aim is responsible handling of Personal Information, balancing the benefits of activities like research, and data analytics with our other commitments, we do not sell or share information outside of the functions mentioned above for quoting purposes.