Commercial Auto Insurance Quote
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
First Name:
*
Last Name:
*
Business Address:
*
Business Name:
*
Check if Mailing Address is different from above
Mailing Address:
*
Check if Garage Location is different from above
Garage Location:
*
Phone Number
*
Email Address
*
Legal Entity
*
Individual
Sole Proprietor
Corporation
Partnership
LLC
Other
Number of Years in Business
*
Please give a description of your business operations below:
*
Does the risk have or plan on having a US DOT#?:
*
Yes
No
US DOT#:
*
Are all vehicles registered to the company/corp?:
*
Yes
No
Who are they registered to?:
*
Are vehicles used for personal use?
*
Yes
No
Please describe below:
*
Are all the vehicles this entity owns included in this quote request?
*
Yes
No
Please advise why:
*
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
Driver 1
Driver Name
*
Date of Birth:
*
Driver's License No.
*
State Licensed:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Add Another Driver
Remove Driver
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
Liability Amount (CSL):
*
$300,000
$350,000
$500,000
$600,000
$1,000,000
Uninsured Motorist - Bodily Injury (CSL):
*
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:
*
None
$25,000
$500
$1,000
$2,000
$5,000
Hired Auto:
*
Yes
No
Non-Owned Auto:
*
Yes
No
Comprehensive Deductible:
*
Yes
No
Please choose one:
*
No Coverage
$250
$500
$1,000
$2,500
Collision Deductible:
*
Yes
No
Please choose one:
*
No Coverage
$250
$500
$1,000
$2,500
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
Vehicle 1
Year
*
Make
*
Model:
*
VIN #
Gross Vehicle Weight (lbs)
*
Cost New ($)
*
Maximum Radius Mileage
*
Under 50 Miles
Under 100 Miles
Under 250 Miles
Under 500 Miles
Unlimited
Vehicle Use
*
Commercial
Service
Retail
Please describe in detail what the vehicle is used for:
*
If commodity is hauled, please explain:
Add Another Vehicle
Remove Vehicle
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
Loss Information
Have you had any losses in the last three years?
*
Yes
No
Loss #1
Date of Loss:
*
Type of Loss:
*
Fire
Liability
Water
Vandalism
Theft
Other
Amount Paid ($)
*
Add Another Loss
Remove Loss
1
General Information
2
Driver Information
3
Coverage Information
4
Vehicle Information
5
Loss Information
6
Additional Comments
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.
I agree to the
Privacy Policy
,
Terms and Conditions
Submit
Previous
Next