A21 Commercial Auto
Customer Information
Was an interview conducted?
*
Yes
No
{"Yes":["3","4","6"]}
Person interviewed (Must be first and last name):
*
Position and/or title?
*
-- Please Select--
Owner
Bookkeeper
Manager
Assistant Manager
Tenant
Other
{" Other":["5"]}
What was the other title?
*
What date was the interview conducted?
*
January
February
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Day
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1925
Year
Commercial Auto
Check the box if you need to correct the address:
*
Incorrect
{"Incorrect":["9","10","11"]}
Corrected Address
How did you obtain the corrected address?
*
Address:
*
Street address
Street address 2
City
State / Province
zip code
General Information
What type of business operations?
*
-- Please Select--
Adult daycare center hauling
Archaeologist
Auto transport
Commodities transportation (Farm hauling)
Concrete hauling
Crop spraying
Drayage
Hauls used clothing
Heavy equipment hauling
Hot shot delivery
Long haul trucking
Meals on Wheels
Medical transport
Miscellaneous hauling
Oilfield equipment hauling
Oilfield services
Other
Short haul trucking
Sign making
Trucking company
Describe in detail the business operations:
*
Owners, Partners, and Officers
How many owners/partners/officers?
*
-- Please Select--
1
2
3
4
5
6
{"1":["17","18","19","20"]," 2":["17","18","19","20","21","22","23","24"]," 3":["17","18","19","20","21","22","23","24","25","26","27","28"]," 4":["17","18","19","20","21","22","23","24","25","26","27","28","29","30","31","32"]," 5":["17","18","19","20","21","22","23","24","25","26","27","28","29","30","31","32","33","34","35","36"]," 6":["17","18","19","20","21","22","23","24","25","26","27","28","29","30","31","32","33","34","35","36","37","38","39","40"]}
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Vehicle Information
Example
*
