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GET A QUOTE – COMMERCIAL AUTOMOBILE
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2022-10-13T12:28:38-05:00
GET A QUOTE FOR YOUR COMMERCIAL AUTOMOBILE
Effective Date of Policy Desired
(Required)
MM slash DD slash YYYY
Detailed Description (Operations) of Services Offered
(Required)
Owner(s)
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physical Address: (if different)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Years of Experience
(Required)
Business Information
Full Name of Business
(Required)
Business Type
(Required)
Sole Proprietorship
Partnership
LLP
LLC
Series LLS
C corporation
S corporation
Nonprofit Corporation
Benefit Corporation
L3C
Business Start Date
(Required)
MM slash DD slash YYYY
Mailing Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physical Address: (if different)
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you have current coverage in place?
(Required)
Yes
No
If so, who is the insurance company(s)
(Required)
How many years with this company?
(Required)
Have any claims been filed in the last 5 years?
(Required)
Commercial Auto Coverage
Are all vehicles titled in the Business Name?
(Required)
Yes
No
If not, please explain
(Required)
Do any your employees ever use their own car in the course of business?
(Required)
Yes
No
Do any your employees ever rent cars in the company’s names?
(Required)
Yes
No
DOT#
(Required)
MC#
(Required)
Do you require any state of federal filings?
(Required)
Yes
No
If so, which filings numbers are needed?
(Required)
Vehicle List
VEHICLE 1
VEHICLE 1 - Year
(Required)
VEHICLE 1 - Make
(Required)
VEHICLE 1 - Model
(Required)
VEHICLE 1 - Cost New
VEHICLE 1 - VIN #
(Required)
VEHICLE 1 - Gross Weight
(Required)
VEHICLE 1 - Full Coverage
(Required)
Yes
No
VEHICLE 1 - RADIUS
(Required)
VEHICLE 2
VEHICLE 2 - Year
VEHICLE 2 - Make
VEHICLE 2 - Model
VEHICLE 2 - Cost New
VEHICLE 2 - VIN #
VEHICLE 2 - Gross Weight
VEHICLE 2 - Full Coverage
Yes
No
VEHICLE 2 - RADIUS
VEHICLE 3
VEHICLE 3 - Year
VEHICLE 3 - Make
VEHICLE 3 - Model
VEHICLE 3 - Cost New
VEHICLE 3 - VIN #
VEHICLE 3 - Gross Weight
VEHICLE 3 - Full Coverage
Yes
No
VEHICLE 3 - RADIUS
VEHICLE 4
VEHICLE 4 - Year
VEHICLE 4 - Make
VEHICLE 4 - Model
VEHICLE 4 - Cost New
VEHICLE 4 - VIN #
VEHICLE 4 - Gross Weight
VEHICLE 4 - Full Coverage
Yes
No
VEHICLE 4 - RADIUS
VEHICLE 5
VEHICLE 5 - Year
VEHICLE 5 - Make
VEHICLE 5 - Model
VEHICLE 5 - Cost New
VEHICLE 5 - VIN #
VEHICLE 5 - Gross Weight
VEHICLE 5 - Full Coverage
Yes
No
VEHICLE 5 - RADIUS
Driver List
DRIVER 1
Driver 1 - Name
(Required)
First
Last
Driver 1 - DOB
(Required)
MM slash DD slash YYYY
Driver 1 - DL#
(Required)
DRIVER 1 - DL State
(Required)
DRIVER 1 - CDL y/n Year Issued
DRIVER 1 - Tickets/Accidents/Claims
(Required)
DRIVER 2
Driver 2 - Name
First
Last
Driver 2 - DOB
MM slash DD slash YYYY
Driver 2 - DL#
DRIVER 2 - DL State
DRIVER 2 - CDL y/n Year Issued
DRIVER 2 - Tickets/Accidents/Claims
DRIVER 3
Driver 3 - Name
First
Last
Driver 3 - DOB
MM slash DD slash YYYY
Driver 3 - DL#
DRIVER 3 - DL State
DRIVER 3 - CDL y/n Year Issued
DRIVER 3 - Tickets/Accidents/Claims
DRIVER 4
Driver 4 - Name
First
Last
Driver 4 - DOB
MM slash DD slash YYYY
Driver 4 - DL#
DRIVER 4 - DL State
DRIVER 4 - CDL y/n Year Issued
DRIVER 4 - Tickets/Accidents/Claims
DRIVER 5
Driver 5 - Name
First
Last
Driver 5 - DOB
MM slash DD slash YYYY
Driver 5 - DL#
DRIVER 5 - DL State
DRIVER 5 - CDL y/n Year Issued
DRIVER 5 - Tickets/Accidents/Claims
Coverages Requested
Coverages Requested:(in dollars)
(Required)
Circle Personal Injury Protection or Medical Payments (in dollars)
(Required)
Uninsured/ Underinsured Motorist
(Required)
Comprehensive Deductible (in dollars)
(Required)
Collision Deductible (in dollars)
(Required)
Hired Auto Limit – indicate annual cost of Hire (in dollars)
(Required)
Nonowned Limit – indicate # of employees
(Required)
Additional Notes
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