General Information Name of Insured: Address: City:   State:   Zip: Business Phone:   Fax Number: Email Address: Garaging Address  (type "same" if same as above): City:   State:   Zip:

Coverage Information Liability Amount (csl): Select One $300,000 $350,000 $500,000 $600,000 $1,000,000 Uninsured Motorist - Bodily Injury (csl): Select One None $25,000 $50,000 $60,000 $100,000 $250,000 $350,000 $500,000 $1,000,000 Uninsured Motorist - Property Damage: Yes   No Medical: Select One None $500 $1,000 $2,000 $5,000 Hired Auto: Yes   No Non-Owned Auto: Yes   No Comprehensive Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000 Collision Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000

Vehicle Information You can list up to 5 vehicles on this form. Reuse this form multiple times for additional vehicles AUTO #1 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

 

AUTO #2 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

 

AUTO #3 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

 

AUTO #4 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

 

AUTO #5 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

 

Driver Information (include all drivers of commercial vehicles at your business) Driver #1 Driver's Name Drivers License Information DL#: State: Yr's Licensed: Job Title Date of Birth Sex How Long w/ Company Courses Completed Last 3 yrs M F Please Select Less than 1 year 1 year 2 years 3 years 4 years 5 years More than 5 years Drivers Ed: Y N  Accident Prevention: Y N

Driver #2 Driver's Name Drivers License Information DL#: State: Yr's Licensed: Job Title Date of Birth Sex How Long w/ Company Courses Completed Last 3 yrs M F Please Select Less than 1 year 1 year 2 years 3 years 4 years 5 years More than 5 years Drivers Ed: Y N  Accident Prevention: Y N

Driver #3 Driver's Name Drivers License Information DL#: State: Yr's Licensed: Job Title Date of Birth Sex How Long w/ Company Courses Completed Last 3 yrs M F Please Select Less than 1 year 1 year 2 years 3 years 4 years 5 years More than 5 years Drivers Ed: Y N  Accident Prevention: Y N

Driver #4 Driver's Name Drivers License Information DL#: State: Yr's Licensed: Job Title Date of Birth Sex How Long w/ Company Courses Completed Last 3 yrs M F Please Select Less than 1 year 1 year 2 years 3 years 4 years 5 years More than 5 years Drivers Ed: Y N  Accident Prevention: Y N

Loss Information   How many losses have there been in the last 3 years?     (Explain any below)

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

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