Safety Product Order Form--Long Haul Truck

LONG-HAUL TRUCK SAFETY PRODUCT ORDER FORM
FREE FOR POLICYHOLDERS ONLY!!!

Please send me more of the following FREE items:

Accident Kits
Easy to use "tools" for drivers to use following a crash.
YES! Please send me more!
Qty:

Claims Hotline Phone Sticker
Stick them in your trucks, on your cell phones, your laptop, etc.
If you have an accident, you'll be glad you did.
YES! Please send me more!
Qty:

Claims Reporting Wallet Cards
Place these cards in your wallet and be sure to report all accidents immediately.
YES! Please send me more!
Qty:

Compliance Hotline Wallet Cards
Place this card in your wallet and begin using the Lancer Compliance Hotline today!
YES! Please send me more! Qty:

Please send them to the street address below (no P.O. boxes):

Your Name:

Policy Number (optional):

Company:

Company Address:

P.O. Box:

City:

State:

Zip:

Tel:

( )

Fax:

( )

Email:

Please click on the "submit" button below
to send this form electronically.
For any questions please call our Customer Service Department at
1-800-782-8902 ext. 3307