Forms

Insurance Release Form

To: Moore Brothers Transport LTD.

For insurance purposes, I am requesting your assistance in validating my insurance coverage with your company. I hereby authorize you to prepare a Letter of Experience and send it to the Insurance Broker as noted herein.

Your co-operation is greatly appreciated. Thank you.

Print Name(Required)

Driver License #(Required)

Home Address

City, Prov., Postal

Home Tel

Fax

Email address

Dates Employed

Fleet Name (if applicable)

Fleet Policy # (if applicable):

Email(Required)

Insurance Broker: Jones DesLauriers Insurance Management Inc. Tel: (416) 259-4625 ~ Fax: (416) 259-7178

Please note that some insurance companies may be unable to release driving experience information to an Insurance Broker. If this is the case, the insurance company will mail/fax the confirmation letter directly to your home address. For more information, feel free to contact us at the telephone number shown above.

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