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(*) Must be filled in.

 
Your Quotation Number or Date of Quote: Quote Number or (DD/MM/YYYY)
Titan Contact :
Shippers First Name:*
Shippers Last Name:*
Service Ordered:*
Receiving Terminals:

Address for contents being dropped off by owner or representative.

 

Pick up Address
For shipments to be picked up by Titan:
Billing Address:*
Phone: *
Fax:*

E-mail:*
Confirmed Pick-up Date:
Social Security or Passport #:*
   

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Automobile #1 Details Automobile #2 Details
Type Type
Model: Model:
Make: Make:
Year: Year:
Vehicle Information Number (VIN) Vehicle Information Number (VIN)
Declared Value: $ Value Declared Value: $ Value
Vehicle Condition: Running Not Running Vehicle Condition: Running Not Running

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Premium Charge Commodity Type Coverage Deductible
 1.85 % of Declared Value Autos – Commercial Total Loss Fire – Theft - Loss ONLY $ 0.00
 2.00 % of Declared Value Autos – Commercial All Risks Damage- Fire -Theft - Loss $500.00
 2.50 % of Declared Value Autos – Commercial All Risks Damage- Fire -Theft - Loss $ 250.00
   
Automobile 1 Marine Insurance Requested: Yes No   $ Insured Value
Automobile 2 Marine Insurance Requested: Yes No   $ Insured Value

*** I have read and agree to the terms of the insurance agreement (click here)

 

 
Consignee Name: *
Consignee Contact Address:*
Destination Port of Entry:*
Destination Country: *
Consignee Phone: *
AGREED RATE:$*
Comments:
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