Paul Arnold Associates, Inc.
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Effective Date of Coverage:
Company Name:
Year Established:
Address:
Phone:
Fax:
Email:
FEIN:
Garage Address:
Where are you going? 1.
2.
3.
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MC Number:
DOT Number:
Do you visit Canada?
Do you visit Mexico?
Est. Revenue past 5 years
Est. Mileage past 5 years
Any private passenger cars?
Step Stools used?
Reflective Tape used?
GPS or other?
Accident Cameras?
How many mechanics?
If none, who provides Maintenance?
Drug/Alcohol Testing?
Physical for Drivers?
Workers Compensation?
How many Drivers? (Please provide schedule)
Number of vehicles (Please provide schedule)
Ownership
Do you allow others to run under your authority?
Current Broker



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Paul Arnold Associates, Inc.
230 Route 206, Suite 304 - P.O. Box 805 Flanders, New Jersey - 07836
Tel: 973-927-0084 Fax: 973-927-0155 Toll Free: 866-287-7867