aGENT FILLED Commercial auto Legal Name of Business * DBA, if any Location of Business * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing address - leave blank if same as above Description of Business * Business Phone (###) ### #### Entity Type * Sole Proprietor Partnership Corporation LLC EIN, if applicable Employer's Identification Number Year current business started * Total Years Experience * Contact Person * First Name Last Name Contact's Mobile Phone * (###) ### #### Contact's Email * Date of Birth * MM DD YYYY Preferred Method of Contact * Phone call Text message Email Prior Insurance? * Yes No If yes, list company name Any claimes filed? * No Yes Liability limits * 30/60 50/100 100/300 250/500 PIP limits * No PIP Coverage 30/60 50/100 100/300 250/500 UM limits * No UM Coverage 30/60 50/100 100/300 250/500 Line Driver List * Include Names, DOB, Marital Status, DL # Vehicle 1 VIN * Vehicle 1 Year, Make, Model * Vehicle 1 Value Vehicle 1 Usage Commercial Only Personal Only Both Vehicle 1 Coverage Liability Only Full Coverage Vehicle 1 deductible Leave blank if liability only Vehicle 1 Trips per day 1 trip per day 2-3 trips per day 5 or more trips per day A) Vehicle 2 VIN B ) Vehicle 2 Year, Make, Model C) Vehicle 2 Value D) Vehicle 2 Usage Commercial Only Personal Only Both E) Vehicle 2 Coverage Liability Only Full Coverage F) Vehicle 2 deductible Leave blank if liability only G) Vehicle 2 Trips per day 1 trip per day 2-3 trips per day 5 or more trips per day A) Vehicle 3 VIN B ) Vehicle 3 Year, Make, Model C) Vehicle 3 Value D) Vehicle 3 Usage Commercial Only Personal Only Both E) Vehicle 3 Coverage Liability Only Full Coverage F) Vehicle 3 deductible G) Vehicle 3 Trips per day 1 trip per day 2-3 trips per day 5 or more trips per day A) Vehicle 4 VIN B ) Vehicle 4 Year, Make, Model C) Vehicle 4 Value D) Vehicle 4 Usage Commercial Only Personal Only Both E) Vehicle 4 Coverage Liability Only Full Coverage F) Vehicle 4 deductible G) Vehicle 4 Trips per day 1 trip per day 2-3 trips per day 5 or more trips per day A) Vehicle 5 VIN B ) Vehicle 5 Year, Make, Model C) Vehicle 5 Value D) Vehicle 5 Usage Commercial Only Personal Only Both E) Vehicle 5 Coverage Liability Only Full Coverage F) Vehicle 5 deductible G) Vehicle 5 Trips per day 1 trip per day 2-3 trips per day 5 or more trips per day TRAILERS Trailer Type Option 1 Option 2 Thank you! Your info has been sent to one of our agents. We will contact you shortly with some rates
