VEHICLE INFORMATION

(*) Must be filled in.

Your Quotation Number or Date of Quote:

Quote Number or (DD/MM/YYYY)

BASI 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 BASI:

Billing Address:*

Phone: *

Fax:*

E-mail:*

Confirmed Pick-up Date:

Unit #1 Details		Unit #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

Unit #3 Details
Type
Model:
Make:
Year:
Vehicle Information Number (VIN)
Declared Value:	$ Value
Vehicle Condition:	Running Not Running

INSURANCE

Premium Charge	Commodity	Type	Coverage	Deductible
2.0 % of Declared Value	Autos – Commercial	Total Loss	Fire – Theft - Loss ONLY	$ 0.00

Automobile 1 Marine Insurance Requested:

Yes No $ Insured Value

Automobile 2 Marine Insurance Requested:

Yes No $ Insured Value

Consignee Name: *

Consignee Contact Address:*

Destination Port of Entry:*

Destination Country: *

Consignee Phone: *

AGREED RATE:$*

Comments:

How did you hear of us?

FREE QUOTE

	A BASI contact us will get back to you within 24 hours
	Select Service:

	Vehicle Make:

	Shipping From:
	City, State
	Destination
	Country
	Name:*

	Telephone Number:*

	Email:*

	Comments:

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