BUSINESS AUTO QUOTE REQUEST

Please fill in as much information as possible, as it will help us serve you more effectively.

Only fill in for your specific number of vehicles and drivers

Applicant Information

Name (required)

Mailing Address

City

State

Zip Code
 

Physical Address

City

State

Zip Code

Phone

Fax

E-Mail (required)

A. Vehicle Information

           Year of Make

           Make, Model

           VIN number/ Registered State

          Leased/Loan or Owned
         Lease/Loan  Own 

                   Date Leased/Purchased

          New or Used
         New  Used 

          Cost New

                  $

        Usage
       Commercial  Retail  Farm

        Pleasure  Service

         Radius  Traveled

                    miles

        Drive distance to work/school

         < 15 miles  15 + miles 

       Any special or modified equipment?  (please list all and briefly describe)

Garage Address

City

State

Zip Code

if no more vehicles, please skip to section E

B. Vehicle Information

            Year of Make

           Make, Model

           VIN number/ Registered State

          Leased/Loan or Owned
         Lease/Loan  Own 

                   Date Leased/Purchased

          New or Used
         New  Used 

          Cost New

                  $

        Usage
       Commercial  Retail  Farm

        Pleasure  Service

         Radius  Traveled

                    miles

        Drive distance to work/school

         < 15 miles  15 + miles 

       Any special or modified equipment?  (please list all and briefly describe)

Garage Address

City

State

Zip Code

if no more vehicles, please skip to section E

C. Vehicle Information

      Year of Make

           Make, Model

           VIN number/ Registered State

          Leased/Loan or Owned
         Lease/Loan  Own 

                   Date Leased/Purchased

          New or Used
         New  Used 

          Cost New

                  $

        Usage
       Commercial  Retail  Farm

        Pleasure  Service

         Radius  Traveled

                    miles

        Drive distance to work/school

         < 15 miles  15 + miles 

       Any special or modified equipment?  (please list all and briefly describe)

Garage Address

City

State

Zip Code

if no more vehicles, please skip to section E

D. Vehicle Information

      Year of Make

           Make, Model

           VIN number/ Registered State

          Leased/Loan or Owned
         Lease/Loan  Own 

                   Date Leased/Purchased

          New or Used
         New  Used 

          Cost New

                  $

        Usage
       Commercial  Retail  Farm

        Pleasure  Service

         Radius  Traveled

                    miles

        Drive distance to work/school

         < 15 miles  15 + miles 

       Any special or modified equipment?  (please list all and briefly describe)

Garage Address

City

State

Zip Code

if no more vehicles, please skip to section E

E. Driver Information

Name (as it appears on license)

Drivers License Number

Social Security Number

Date of Birth

Sex
Male  Female

Marital Status
Married  Single

if no more drivers, please skip to section I

F. Driver Information

Name (as it appears on license)

Drivers License Number

Social Security Number

Date of Birth

Sex
Male  Female

Marital Status
Married  Single

if no more drivers, please skip to section I

G. Driver Information

Name (as it appears on license)

Drivers License Number

Social Security Number

Date of Birth

Sex
Male  Female

Marital Status
Married  Single

if no more drivers, please skip to section I

H. Driver Information

Name (as it appears on license)

Drivers License Number

Social Security Number

Date of Birth

Sex
Male  Female

Marital Status
Married  Single

I. Applies to all of the above applicants

Accident, regardless of fault, or been convicted of a moving violation?

           Yes

           Please list the date, description, place, and property damage value of accident/violation.
         

General Information

With the exception of any encumbrances, are any vehicles not solely owned by and registered to the applicant?
Yes  No 

Do over 50% of the employees use their own autos in business?
Yes  No 

Is there a vehicle maintenance program in existence?
Yes  No 

Are any vehicles leased to others?
Yes  No 

Any car modified or hold special equipment ?
Yes  No 

Do operations include transporting hazardous material ?
Yes  No 

Any hold harmless agreements?
Yes  No 

Any vehicles used by family members?
Yes  No 

Does applicant obtain MVR verifications?
Yes  No 

Does applicant have a specific driver recruiting method?
Yes  No 

Are any drivers not covered by workers compensation?
Yes  No 

Any vehicles owned but not scheduled on this application?
Yes  No 

Any drivers with convictions for moving violations?
Yes  No 

Limits of Liability

Single Limit Liability

$

Uninsured/Underinsured Motorist Liability

$

Hired/Borrowed Liability

$

Medical Payments Liability

$

Towing & Labor
$

Non Owned Liability
$

 Comprehensive Deductibles

         Comprehensive Deductible Car 1
         $

         Comprehensive Deductible Car 2
         $

         Comprehensive Deductible Car 3
         $

         Comprehensive Deductible Car 4
         $

Collision Deductibles

        Collision Deductitble Car 1

        $

         Collision Deductible Car 2

        $

         Collision Deductible Car 3

        $  

        Collision Deductible Car 4

        $

Comments

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