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Commercial Auto Quote Request From
Insured's Name:
Ph:
Fax:
Email Address:
DBA:
Organization Type:
Adress:
City:
Zip:
FEIN or Social Security Number
Year Business Start
Home address
Prior Insurance
Expiration Date:
Name:
(First - M - Last)
Driver 01
Driver 02
Diver 03
Date of Birth:
Driving License Number
Date Hire
Sex
Male
Female
Male
Female
N/A
Male
Female
N/A
Marital Status
M
W
S
D
M
W
S
D
N/A
M
W
S
D
N/A
Driving Experience Years:
First License Issued:
Any Ticket?
If Yes, provide detail
Any Accident?
If Yes, provide detail
Detail Driver 01:
Detail Driver 02:
Detail Driver 03:
CAR Information
Car 01
Car 02
Car 03
Current Values
VIN Number Or Make / Model L/Yr
LE / CE / SE - ETC
Coverages
Full
Liability
Full
Liability
N/A
Full
Liability
N/A
Deductible
$500
$1000
$500
$1000
N/A
$500
$1000
N/A
Unisured Motorist
Yes
No
Yes
No
N/A
Yes
No
N/A
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES
1. WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?
Yes
No
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. ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE SPECIAL EQUIPMENT?
Yes
No
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 MEMBERS? IF SO, IDENTIFY IN REMARKS.
Yes
No
10. DOES THE APPLICANT OBTAIN MVR VERIFICATIONS?
Yes
No
11. DOES THE 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 SCHEDULED ON THIS APPLICATION?
Yes
No
14. ANY DRIVERS WITH MOVING TRAFFIC VIOLATIONS?
Yes
No
15. HAS AGENT INSPECTED VEHICLES?
Yes
No
LIMIT & COVERAGE’S DESIRED
1) Liability Physical Damage ( PLEASE CHECK ONE )
15/30/05
25/50/15
50/100/25
100/300/50
250/500/100
100 Combine Single Limit
300 CSL
500 CSL
600 CSL
750 CSL
1M CSL
N/A
2) Hired Auto
3) Non owned auto
15/30/05
N/A
15/30/05
N/A
(cost of hire must be at least $5000)
How many Employees?