We would like to provide you with a free, no-obligation commercial automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
General Information
Name of Insured:
Business Address:
City:
State:
Zip:
Is the garaging address the same as the business address?
Y
N
Garaging Address:
City:
State:
Zip:
Business Phone:
Fax Number:
Email Address:
Business Tax ID#:
# of drivers to be included:
Has Insured had:
Continuous coverage for at least one year?
Y
N
President / CEO
First Name:
Last Name:
Suffix:
Involved with:
Daily business operations?
Y
N
Date of Birth:
(mm/dd/yyyy)
Home Address:
How Did You Hear About Us?
Please check all that apply:
Search Engine
Social Network
Advertisement
Family or Friend
Forum/Blog
Co-Worker
Other:
Current Commercial Auto Insurance Information
Company Name (not agency):
Policy Expiration Date:
Premium Amount: $
Term:
6 Months
1 Year
Other:
Underwriting Questions
Does the insured have a General Liability Insurance or Business Owner's Policy?
Year current business was established:
Number of Additional Insureds:
Number of Waiver of Subrogation:
Policy Filings
Are any state or federal filings required?
Y
N
Do we insure all commercial vehicles the insured owns?
Y
N
Do we insure all vehicles that the insured uses in their business?
Y
N
Filing Types
Federal:
Y
N
MCS90:
Y
N
Federal Cargo (BMC-34):
Y
N
State:
State Cargo (Form H):
Other: (0-9):
Desired Coverage Information
Liability Amount (csl):
Uninsured Motorist - Bodily Injury (csl):
Uninsured Motorist - Property Damage:
Yes
No
Medical:
Motor Trucking Cargo:
Yes
No
Downtime/Rental (if available):
Yes
No
Roadside Assistance (if available):
Yes
No
Hired Auto:
Yes
No
Non-Owned Auto:
Yes
No
Comprehensive Deductible:
Yes
No
If "Yes",
Collision Deductible:
Yes
No
If "Yes",
Vehicle Information
You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles
AUTO #1
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius (in miles, one way)
Vehicle Use
lbs.
$
Is this vehicle garaged at a location other than mailing/business address:
Y
N
Please describe in detail what the vehicle is used for:
If commodity is hauled, please explain:
AUTO #2
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius (in miles, one way)
Vehicle Use
lbs.
$
Is this vehicle garaged at a location other than mailing/business address:
Y
N
Please describe in detail what the vehicle is used for:
If commodity is hauled, please explain:
AUTO #3
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius (in miles, one way)
Vehicle Use
lbs.
$
Is this vehicle garaged at a location other than mailing/business address:
Y
N
Please describe in detail what the vehicle is used for:
If commodity is hauled, please explain:
AUTO #4
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius (in miles, one way)
Vehicle Use
lbs.
$
Is this vehicle garaged at a location other than mailing/business address:
Y
N
Please describe in detail what the vehicle is used for:
If commodity is hauled, please explain:
AUTO #5
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius (in miles, one way)
Vehicle Use
lbs.
$
Is this vehicle garaged at a location other than mailing/business address:
Y
N
Please describe in detail what the vehicle is used for:
If commodity is hauled, please explain:
Loss Information
How many losses have there been in the last 3 years?
(If any, please explain below)
Driver Information
(include all licensed drivers in your business)
Driver #1
Driver's Name
Drivers License Information
DL#:
State:
Yrs Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M F
Married Single
Drivers Ed:Y
N Accident Prevention:Y
N
SR22 Filing
FR44 Filing
Mailing Address
Y
N
Y
N
Driver #2
Driver's Name
Drivers License Information
DL#:
State:
Yrs Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M F
Married Single
Drivers Ed:Y
N Accident Prevention:Y
N
SR22 Filing
FR44 Filing
Mailing Address
Y
N
Y
N
Driver #3
Driver's Name
Drivers License Information
DL#:
State:
Yrs Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M F
Married Single
Drivers Ed:Y
N Accident Prevention:Y
N
SR22 Filing
FR44 Filing
Mailing Address
Y
N
Y
N
Driver #4
Driver's Name
Drivers License Information
DL#:
State:
Yrs Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M F
Married Single
Drivers Ed:Y
N Accident Prevention:Y
N
SR22 Filing
FR44 Filing
Mailing Address
Y
N
Y
N
Driver History
List ANY convictions for ANY driver convicted of moving traffic violations in the past 5 years
Driver
Date
Type of Conviction
Fines
Speed Over Limit
$
mph
$
mph
$
mph
$
mph
Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended
Revoked
Alcohol
Drugs
Suspended
Revoked
Alcohol
Drugs
Suspended
Revoked
Alcohol
Drugs
Suspended
Revoked
Alcohol
Drugs
Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Fines
Injuries
At Fault
$
$
Yes
Yes
$
$
Yes
Yes
$
$
Yes
Yes
$
$
Yes
Yes
Additional Comments
Please give any additional comments you feel appropriate for this quotation.
If you have additional information where there was not enough fields above, please
enter them here.
Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible.
