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Back to Express Requests

Truckers Express Request

*Complete and submit the form below for an Express Premium Indication from OGA’s Small Business Unit

Fax: 405.840.9388 | 800.771.8116
Phone: 405.840.9393 | 800.299.1951

Agency Information
Applicant Information

Please list each as: Commodity | Percentage of Loads | Maximum Value | Average Value

E.G.: Copper | 25% | $30,000 | $15,000

Describe the usual route(s) including largest city entered

Prior Carriers & Loss Information

Please list each as: Company Name | Policy Date | Policy Number | Premium | Number of Units

E.G.: Company X | 10/05/2011 | 121222 | $20,000 | 5 Units

Include 3 year history

Driver’s Information
Limits & Coverage
$
$
$
$

If yes, Hired & Non-Owned supplemental form is required.

$

Will need non-driver payroll.

$
$

If yes, copy of Trailer Interchange Agreement is required.

Description of Units
$

Must be current market value

Please Note

*Fully completed company specific applications and any applicable supplemental questionnaires are required prior to binding. The premium may change upon receipt of company applications and required supplementals.

If needed, please include any comments or additional information here.

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