June 24, 2017

Commercial Auto Quote

Business Information
Contact Name *
Contact Email *
How did you hear about us? *

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
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
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Drivers
  Full Name Date of Birth Drivers License # License State CDL? Marital Status
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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.