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Commercial Auto
"20 Question Quote" Form

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

1. Insured Name:
  Phone Number:
  E-mail:
2. Business Name:
  Business Website:
3. Address:
  City:
  State:     Zip:
4. Garaging Address of Vehicle (if different from above):
  Address:
  City:
  State:     Zip:
5. Tax ID Number:
6. Effective Dates: to
7. Desired/Renewal Premium:   (Don’t Know )
8. Current Insurer:
9. Years in Business:
10. Legal Entity (LLC?  Corp?  Partnership?):
11. Nature of Business/Description of Operations:
12. How is Vehicle Used:
13. Liability Limits Desired:
  Gross Vehicle Weight:
14. Physical Dam Deductibles Desired:
  Radius of Operation:
  Cost Vehicle New:
15. Vehicle Information:
 
Vehicle #1 Year Make Model
Vehicle #2 Year Make Model
Vehicle #3 Year Make Model
Vehicle #4 Year Make Model
16. Driver Information:
 
Driver #1 Name License No. DOB
Driver #2 Name License No. DOB
Driver #3 Name License No. DOB
Driver #4 Name License No. DOB
17. Coverage Needed:
  Additional PIP                  Comprehensive
  Medical Payments          Collision
  Towing/Labor                  Hired/Non-Owned Auto Rental
18. Please list all accidents past 3 years:
19. Please list all moving violations last 3 years:
20. Have you been canceled for non-payment of premium within the last 3 years?:
Yes No
   

REQUIRED. By checking this box, I understand that the information above is to garner an indication only.  Coverage can not be bound without additional information, including a signed application.  All indications are pending favorable loss history for prior 3 years and favorable MVRs.



 
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