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PAYMENT MODIFICATION REQUEST
All fields are required
Customer Full Name (Name on the Contract):
US Customers
Canadian Customers
Account Number:
Your Name:
Your Phone Number:
Your Email Address:
Industry:
Refrigerated
Flatbed
Dry Van
Heavy Haul
Tanker
Energy (Oil/Gas)
Construction
Lease/Rental
Agriculture
Refuse
Logging
Other
Type of Freight Hauled:
Primary Customers / Hauls (Top Two):
Customer / Haul Name:
Contact Name:
Phone Number:
1)
2)
Percent of Revenue Generated From Spot Market:
0-5%
5-10%
10-20%
20-30%
30-40%
Over 40 %
N/A
Total Trucks in Fleet / Operate:
Total Trucks Currently Working / Generating Revenue (Utilization):
Insurance Provider:
Insurance Contact Name:
Insurance Phone Number:
Insurance Effective Date:
Insurance Expiration Date:
Describe Your Current Situation:
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