Insurance Service Center

Business Auto Quote Request

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Please send this information with attention to:

i. Contact Information: (* = required fields)

*Business Name		*Office Phone:
*Contact Name:		Cell Phone:
*Business Address:		Fax #:
*City:
*State:	*Zip:

*Email Address:
*Confirmation of Email Address:

When is the best time to reach you?

What is the best way to reach you?

ii. Prior Insurance Information:

Are you currently insured? Yes No
	If yes, then:
	Who is your current Business Auto Insurance Carrier?
	Approximately how much are you paying for your Business Auto Insurance coverage?

iii. Business Information:

What type of entity is your business?

Please give a detailed description of your business operations?
The more information you give will help us best classify your business. (required field)

iv. Vehicle Information:

Give the VIN#(s), Year(s), Make(s) & Model(s) for every Vehicle to be included. Please note, although it take a bit more time to find the VIN#(s) and supply it to us, it allows us to give you the most accurate quote possible.
	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Vehicle Type:
Year:
Make:
Model:
Body Style:
Gross Weight:
VIN #:
Confirmation of VIN #:
This vehicle is used for:
	Other:	Other:	Other:	Other:
Radius of Use:
Zip Code where Vehicle is garaged?:

v. Discounts:

Vehicle # 1	Vehicle # 2	Vehicle # 3	Vehicle # 4
Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint
Daytime Lights	Daytime Lights	Daytime Lights	Daytime Lights
Anti-lock Brakes	Anti-lock Brakes	Anti-lock Brakes	Anti-lock Brakes
Active Anti-theft Passive Anti-theft	Active Anti-theft Passive Anti-theft	Active Anti-theft Passive Anti-theft	Active Anti-theft Passive Anti-theft

vi. Driver Information:

Name	Sex	Driver's License State	Commercial Driver's License	Marital Status	Date of Birth (mm/dd/year)	Vehicle Driven
			Yes No
			Yes No
			Yes No
			Yes No

vii. Accident & Ticket Information:

Incident	Driver Involved	Ticket/Violation	Violation Date (MM/DD/YYYY)
1
2
3
4

viii. Coverage Information:

Liability:
	Bodily Injury Limits:
	Property Damage Limits:
	Uninsured & Underinsured:
	Medical Payments:
Coverages & Deductibles:
	Comprehensive Deductible:
	Collision Deductible:
Optional Coverages:
	Rental Reimbursement:
	Towing Limit Options:
	Do you hire any drivers?	Yes No
	Do any of your employees ever drive their own vehicles doing business? This might include a trip to the bank or simply driving from the office to an appointment.	Yes No

ix. Other Coverages:

Are you interested in any of the following:

Workers' Compensation
General Liability
Business Property and/or Building Coverage
Other


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