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COVID-19 PAYMENT MODIFICATION REQUEST
All fields are required
Customer Full Name (Name on the Contract):
Account Number:
Your Name:
Your Phone Number:
Your Email Address:
Industry:
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:
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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