Name: Flagship Insurance Agency
Address: 651 Orchard Street, New Bedford, MA, 02744, US
Telephone: (508) 994-9688

Insured Name (and Phone Number):
Business Name (& Website):
Insured Address
Street Address Address Line 2 City State ZIP Code
Garaging Address of Vehicle (if different from above)
Street Address Address Line 2 City State ZIP Code
Federal Tax ID:
Effective Dates (from and to):
Desired/Renewal Premium:
Current Insurer:
Years in Business:
Legal Entity (LLC? Corp? Partnership?):
Nature of Business/Description of Operations
How is Vehicle Used:
Limit of Liability Desired:
Gross Vehicle Weight:
Physical Dam Deductibles Desired:
Radius of Operation:
Cost Vehicle New:
Vehicles
Make Model Year
Drivers
Name License Number Date of Birth
Coverages Needed
- Additional PIP
- Comprehensive
- Medical Payments
- Collision
- Hired/Non Owned Auto Rental
- Towing/Labor
Please list all accidents past 3 years:
Please list all moving violations last 3 years:
Have you been canceled for non-payment of premium within the last 3 years?
Please note, 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.

Make	Model	Year

Name	License Number	Date of Birth

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