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Commercial Auto

Please fill out the form below. You may also fill out our short form by clicking here.

General Information
How did you hear about us? *
BIA Chamber of Commerce
Current Client Email
Google Yahoo
Mailer Yellow Pages
Referral: Website:
Other:  
Named Insured: *
 Contractor's License #:
Owner's Name: *
 Contact's Name: *
Phone: *
 Fax:
Cell:
Email Address: *
 Preferred method of contact: *
Phone Fax Email Mail
Address Information
Mailing Address
Street: *
City: *
State: *
Zip: *
 
Premise Address
Street:
City:
State:
Zip:
Business Entity: *
Sole Proprietorship Partnership Corporation LLC Other:
Carrier Information
Current Auto Carrier: Expiration Date:
Driver Information
Drivers Full Name DOB License Number Marital Status Violation / Accidents
inthe last
3 years?
Single
Married
Divorced		 Yes No
Single
Married
Divorced		 Yes No
Single
Married
Divorced		 Yes No
Vehicle Information
Year Make / Model / Body Type VIN Gross Weight Value Radius of
Operations (miles)
< 50
50-100
> 100
< 50
50-100
> 100
< 50
50-100
> 100
Desired Coverages
****Liability - Split Limits or CSL**** Comp / Coll Ded ****Uninsured Motorist BI**** Uninsured Motorist PD Hired & Non - Owned Auto Medical Payments
15/30/10
50/100/50
100/300/50
250/500/100
300,000
500,000
750,000
1,000,000
Other

If Other:
 250
500
1,000
2,500
Other

If Other:
 15/30
25/50
30/60
50/100
Other

If Other:
 3,500
5,000		 Yes
No		 500
1,000
2,000
5,000
CSL = Combined Single Limit BI = Bodily Injury PD = Property Damage
****ALL VEHICLES MUST CARRY SAME LIABILITY/UNINSURED MOTORIST COVERAGE****
Lender Information
Veh & Account # Lender Name Lender Address Loss Payee Additional Insured
Yes
No		 Yes
No
Yes
No		 Yes
No
Yes
No		 Yes
No
Special Filing Requirements
MCP-65   CA#:
Other
Special Requirements:
Additional Comments
Additional Comments:
Legal Terms
You MUST agree to our terms and conditions to submit this request by doing both of the following:
Applicant's Name (to Agree with Terms: *
Applicant's Initials (to Agree with Terms): *
I/we the undersigned hereby declare that the above statements are true and correct. This is not an application, it is only a preliminary info sheet for a quote. Additional information may be required.
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