Comm Auto Quote
Fields marked (
*
) are mandatory.
General Information
Named Insured
*
Corp. Name (DBA)
Eff. Date
Business Information
Mailing Address
*
Primary Location
Nature of Business
Years in Business
F.E.I.N.
Current Policy Information
Canc/Non-Renewed/Decl. Last 3 years
No
Yes
If Yes Explain
Current Premium
Current carrier
Losses last 3 Years
Coverage
Liability Limit
U/M Limit
U/M Property Damage
No
Yes
Medical Payments
No
Yes
Limit
Drivers
Driver #1 (Driver Name D/L#-State
Years Licensed in State DOB Viol/Accs)
*
Driver #2 (Driver Name D/L#-State Years
Licensed in State DOB Viol/Accs)
Driver #3 (Driver Name D/L#-State Years
Licensed in State DOB Viol/Accs)
Driver #4 (Driver Name D/L#-State Years
Licensed in State DOB Viol/Accs)
Driver #5 (Driver Name D/L#-State Years
Licensed in State DOB Viol/Accs)
Vehicles
Vehicle #1 (Year Make/Model Type
GVW Current Value/Vin# of vehical)
*
Vehicle #2 (Year Make/Model Type
GVW Current Value/Vin# of vehical)
Vehicle #3 (Year Make/Model Type
GVW Current Value/Vin# of vehical)
Vehicle #4 (Year Make/Model Type
GVW Current Value/Vin# of vehical)
Vehicle #5 (Year Make/Model Type
GVW Current Value/Vin# of vehical)
Physical Damage
No
Yes
Spec. Perils Deductible
The amount of loss which is
paid or absorbed by the insured prior
to determining the insurance company's liability
Collision deductible
The amount of loss which is paid or
absorbed by the insured prior to determining
the insurance company's liability
Radius of Operation(s)
Filings Needed
No
Yes
If Yes Explain
SR 22 Needed (if Yes Ineligible)
proof of financial responsibility
No
Yes
Livery (Public of Private) Exposure (If Yes Ineligible)
No
Yes
Remarks