New Customer Intake Form

Registered Business Legal Name *

Business Physical Address *

Truck location address:

Do you Lease or Own Truck?

Sales Tax exempt?

(If YES, please email us your company's Resale Certificate or Tax Exemption Certificate)

Insurance Claim?

If yes, please provide insurance information below)

Outsourced Fleet Management Provider Claim? Examples (Fleet Response, Holman (formerly ARI), CEI, etc.)

If YES for Outsources Fleet Management, Please Provide Claim # and Phone Number

Insurance Company & Phone Number

Claim #

Full Name

Phone Number

Full Name

Phone Number

VIN number

or you Business

Unit# or Asset # if any

How did you hear about us?