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General Information
This section only
needs to be completed once for multiple lines of coverage
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Name of Business: |
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Name of Owners/Officers: |
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Contact Name: |
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Contact Phone & Fax: |
Phone:
Fax: |
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Contact E-mail Address: |
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Address:
City: |
State:
Zip: |
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Business Info: |
C-Corporation
S-Corporation
LLC
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Sole-Proprietor
Partnership
LLP/Other |
Years
in Business:
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Fed. Tax ID or Social
Security Number: |
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Business Description: |
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Current/Previous Insurance Information
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Current insurance company: |
Annual Premium:
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Policy Period: |
Effective
Date:
Expiration Date:
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Any Other Carriers
(last 3 years): |
No
Yes
If yes, please list name and estimated premium:
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Any Insurance Claims Filed
(last 3 years):
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No
Yes
If yes, please give following data:
-Date of claims, amount of claims,
description, and cost of claims:
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Vehicle Schedule Information |
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*Note. If you have a large fleet of
vehicle you may skip this section and upload, fax, or
e-mail your fleet schedule along with your limits of
insurance page and your drivers schedule after you
submit the other data.
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Auto #1:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Auto #2:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Auto #3:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Auto #4:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Auto #5:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Auto #6:
Describe vehicle use: |
Year:
Make:
Model:
VIN #:
Gross
Weight:
lbs
Cost New: $
Radius (One Way):
miles
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Insurance Limits Information |
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Liability Limit: |
$1,000,000 $500,000 $300,000 $100,000 Other: |
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Uninsured Motorist Limit: |
$1,000,000
$500,000 $300,000
$100,000
Other: |
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Medical Payments: |
$5,000
Other: |
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Towing Coverage: |
List Vehicle #'s
(above) to Request Towing Coverage:
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Rental Coverage: |
List Vehicle #'s
(above) to Request Rental Coverage:
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Lease Gap Coverage: |
List Vehicle #'s
(above) which are Leased:
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Additional Comments & Information |
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Please tell us anything
else you think might be helpful to know in order to
provide accurate insurance quotes: |
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