Application for Courier InsuranceTo obtain a free, no-obligation quote for your courier insurance, fill out the form below and we will contact you. If you prefer to fill out a form and mail it in, please go to our downloadable form section and print the desired form.If you are unsure of an answer, enter "Unsure"
Applicant Information:
Name Insured
Mailing Address
City State Zip -
Street Address:
Telephone Fax E-mail
Federal Tax ID# Years In Business
Legal Entity Individual Partnership Corporation Other
Contact Person
Description of Operations (Type of work, milleage radius, etc.)
Type of Messengers
Do You Have Contracts With Your Independent Contractors: Yes No*P-T - Part time is 20 hours or less per week on average or drivers earning 50% or less of average full time driver.
Gross Annual Revenue
Last Fiscal Year
Current Fiscal Year (estimate)
Operating Annual Revenue:
Federal Authority: Yes No Docket Number
State Authority Yes No States
Current Insurance Information
Please provide copies of the above policies. We can often obtain additional information from policies that is helpful in putting together our quotation.
IN ADDITION TO THE COMPLETED APPLICATION, WE REQUIRE THE FOLLOWING ITEMS IN ORDER TO CREATE AN ACCURATE QUOTE :
Hard Copy "Loss Runs" for all lines of coverage being quoted for the last four (4) years. (Current year plus three previous). Motor Vehicle Reports (MVR's) for all drivers (not more than 60 days old). If you cannot provide MVR's, we will obtain them for you at our cost of $7.00 each. Please enclose a check for the total made payable to Mattoni Insurance, Inc. We cannot provide a quote without current motor vehicle reports. Policy declarations page for ALL independent contractors/employees driving their own vehicles on behalf of your company. Your Bill of Lading or other shipping receipt. Sample of Independent Contractor Agreement. Copy of current state(s) certificate of authority (if applicable). Copies of any written customer contracts, if applicable.
Completed by (Type Name and Title) Date
