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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.