B Smart - Motor Truck Cargo Smart Insurance - Quote Application Form

Motor Truck Cargo Smart Insurance - Quote Application Form

Application for coverage of goods in motion across Canadian domestic operations, from loading to final delivery.
Broker Information
Broker Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brokerage Name
Insured Information
Company Legal Name
Company Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Contact Name

First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years in Business
Website Address
Subsidiaries (list all subsidiaries to be included)
Description of Operations
List Provinces/Territories of Operation
Do you operate in the United States? Please note: MTC Smart does not currently cover operations outside of Canada
USDOT Number
MC Number

Owl Underwriting Agency Inc. DBA B Smart Insurance
Confirm Form is Complete
THE UNDERSIGNED HEREBY ACKNOWLEDGES THE TRUTH OF THE STATEMENTS CONTAINED HEREIN.

I AUTHORIZE YOU TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS PERMITTED BY LAW, IN CONNECTION WITH YOUR MOTOR TRUCK CARGO INSURANCE POLICY OR A RENEWAL, EXTENSION OR VARIATION THEREOF, FOR THE PURPOSES NECESSARY TO ASSESS THE RISK, INVESTIGATE AND SETTLE CLAIMS, AND DETECT AND PREVENT FRAUD, SUCH AS CREDIT INFORMATION, AND CLAIMS HISTORY.
Signatory Name
Position
Signature
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty:

Motor Truck Cargo Smart Insurance - Quote Application Form