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December 5, 2019
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ARCHITECT & ENGINEERS E & O
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COMMERCIAL AUTO
WORKERS COMPENSATION
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LESSORS RISK
FARM & RANCH INSURANCE
LIFE & HEALTH INSURANCE
GROUP HEALTH INSURANCE
INDIVIDUAL HEALTH INSURANCE
LIFE INSURANCE
SERVICE YOUR POLICY
MAKE A PAYMENT
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ADD A DRIVER
ADD A VEHICLE
REMOVE A VEHICLE
REPLACE A VEHICLE
AUTO ID CARD REQUEST
CERTIFICATE OF INSURANCE REQUEST
WHAT WE DO
BUSINESS INSURANCE
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Commercial Auto Quote
Business Information
Contact Name *
Contact Email *
How did you hear about us? *
Post Card
Website
Referral
Brad Hancock
Scott Kirby
Emory Estes
Susan Elliott
June Landa
Karen Easter
Melissa Cano
Business Name
Address
City
State
Zip
Business Phone
Cell Phone
Fax
Website
Preferred Method of Contact?
Business Phone
Cell Phone
Email
Fax
General Information
FEIN #
Social Security Number
How long in Business? (yrs)
Business Type
Association
Church
Corporation
LLC
Municipality
Non-Profit
Partnership
Sole Proprietor
Other (describe)
Please give a brief description of your business operations
Current Insurance Company
Insurance Company Name
Policy Effective Date
Policy Expiration Date
Policy Number
Coverage Information
Limits Requested
Uninsured Motorist Limits
Personal Injury Protection (PIP) Limits
Hired & Non-Owned Auto Limits
Collision Deductible
Comprehensive Deductible
Towing & Labor
Yes
No
Do any vehicles have any permanently attached equipment? If yes, what is the value and please describe.
Describe any claims you've had in the past 5 years
Additional Comments
Vehicles
Year
Make
Model
VIN #
Collision
Comprehensive
Specified Causes of Loss
Garaging Zip Code
1.
Yes
No
Yes
No
Yes
No
2.
Yes
No
Yes
No
Yes
No
3.
Yes
No
Yes
No
Yes
No
4.
Yes
No
Yes
No
Yes
No
5.
Yes
No
Yes
No
Yes
No
6.
Yes
No
Yes
No
Yes
No
7.
Yes
No
Yes
No
Yes
No
8.
Yes
No
Yes
No
Yes
No
9.
Yes
No
Yes
No
Yes
No
10.
Yes
No
Yes
No
Yes
No
11.
Yes
No
Yes
No
Yes
No
12.
Yes
No
Yes
No
Yes
No
13.
Yes
No
Yes
No
Yes
No
14.
Yes
No
Yes
No
Yes
No
15.
Yes
No
Yes
No
Yes
No
Drivers
Full Name
Date of Birth
Drivers License #
License State
CDL?
Marital Status
1.
Yes
No
Married
Single
Divorced
Widowed
2.
Yes
No
Married
Single
Divorced
Widowed
3.
Yes
No
Married
Single
Divorced
Widowed
4.
Yes
No
Married
Single
Divorced
Widowed
5.
Yes
No
Married
Single
Divorced
Widowed
6.
Yes
No
Married
Single
Divorced
Widowed
7.
Yes
No
Married
Single
Divorced
Widowed
8.
Yes
No
Married
Single
Divorced
Widowed
9.
Yes
No
Married
Single
Divorced
Widowed
10.
Yes
No
Married
Single
Divorced
Widowed
11.
Yes
No
Married
Single
Divorced
Widowed
12.
Yes
No
Married
Single
Divorced
Widowed
13.
Yes
No
Married
Single
Divorced
Widowed
14.
Yes
No
Married
Single
Divorced
Widowed
15.
Yes
No
Married
Single
Divorced
Widowed
Questions
1. With exception of encumberances, are any vehicles not solely owned by the applicant?
Yes
No
If "yes" above - please describe.
2. Do over 50% of the employees use their autos in the business?
Yes
No
3. Is there a vehicle maintenance program in operation?
Yes
No
4. Are any vehicles leased to others?
Yes
No
5. Any car modified/special equipment?
Yes
No
If "yes" above - please describe.
6. Are ICC, PUC or other filings required?
Yes
No
7. Do operations involve transporting hazardous material?
Yes
No
8. Any hold harmless agreements?
Yes
No
9. Any vehicles used by family menmbers?
Yes
No
If "Yes" above - please identify.
10. Does applicant obtain MVR verifications?
Yes
No
11. Does applicant have a specific driver recruiting method?
Yes
No
12. Are any drivers not covered by workers compensation?
Yes
No
13. Any vehicles owned but not listed on this application?
Yes
No
14. Any drivers with convictions for moving violations?
Yes
No
If "yes" above - please provide driver name, violation and date.
Comments
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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