Shipper Load Confirmation
Company Name: Insta Load Brokerage Company
Pro #: ________________________ Insta Load Brokerage Company LLC
LLC______
Shipper: ________________________ Name Street
Address: 3888 Albers Pointe Address
Drive 2 Mo,
Florissant
63034_____
Address: ________________________ Phone: City State Zip
Phone: (314) 492.6499____
________________________ Fax: 110737__
MC# MC # or US DOT :
Contact: ________________________ Confirmation must be signed
Phone # _________________________ & returned before driver
Email: __________________________ can be dispatched. Thanks!
Load Information:
Origin: _____________________________ Destination: __________________________
Location: ____________________________ Location: _____________________________
Contact: ____________________________ Contact: ____________________________
Zip Code:___________________________ Zip Code: _____________________________
Address: ___________________________ Address: _____________________________
Phone:_____________________________ Phone: ___________________________
Model: ____________ Serial# ____________
Weight: ____________ Quantity: _________
Commodity: ______________________
Load Description: ___________________________________________________________________
___________________________________________________________________
Note: This quotation is only an estimate of charges based on the load information provided, this quote is
valid for (14) days. any changes in the load description above may alter the amount charged. if the
commodity value is over $100,000, special cargo insurance is required, and carrier’s agent must be
advised of the declared value. the rate includes all stop-off charges, fuel charges, loading, unloading, etc.
in exchange for the rate set forth herein, it is understood and agreed that the liability of Freight Forwarder
for loss, damage, or delay to cargo is subject to the Carmack Amendment, and is limited to the lesser of
the actual value of the goods or $50,000 per truckload. In the event a higher level of liability is desired,
Shipper Must request such higher limitation in writing and enter into a sign right confirmation agreement
with freight broker prior to scheduled pickup of the shipment at issue with sets forth the amount of
liability requested by shipper an increased freight charges applicable to such request. The limitation set
forth herein shall apply regardless of anything to the contrary contained in the relevant bill of lading,
delivery receipt, or other shipment documentation. Unless superseded by written agreement that expressly
disclaims freight brokers tariff, any transportation performed or arranged here under will be governed by
freight brokers tariff.
Confirmation must be signed and emailed to freight broker before tendering load to freight broker we
understand that this contract has been approved by person authorized to do so if any information is
incorrect, please contact us by telephone or email before executing the above contract.
RATE: $ ________________
PRINTED: ____________________
DATE: _____/_______/___________ SIGNATURE: __________________________
