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Commercial Auto Quick Quote Form


NAMED INSURED (required): Ph:

GARAGING ADDRESS (required):

YOUR EMAIL ADDRESS (required):

NO. OF YEARS IN BUSINESS (With own insurance):

FEIN #:

COMMODITIES HAULED (Be Specific about percent of time):

FILINGS REQUIRED: NoneICCDMV

OTHER

RADIUS:

INTRASTATE (CA only)0-100 MILES101-200 MILES201-300 MILES301-500 MILES

INTERSTATE - EXACTLY WHERE?

DRIVER(S):

NAME AS IT APPEARS ON LICENSE YRS EXP DRIVERS LICENSE NUMBER(S)

*Specify the number of year’s commercial driving experience each driver has. If there are any drivers with a “not at fault” accident, please
provide a copy of the policy report with your submission.

EQUIPMENT:

YEAR MAKE BODY TYPE GVW STATED VALUE DEDUCTIBLE

*If there are 5 or more power units, please provide a completed ACORD or completed company application instead of this form for quoting.

Trailers:

YEAR MAKE BODY TYPE GVW STATED VALUE DEDUCTIBLE

*Please specify if applicant is pulling non-owned trailers and if applicant is pulling doubles.

COVERAGES:

AUTO LIABILITY: $100K CSL$300K CSL$500K CSL$750K CSL$1M CSL OTHER:

AUTO LIABILITY DEDUCTIBLE: $500

UNINSURED MOTORIST BI: $15,000/$30,000$25,000/$50,000$30,000/$60,000

CARGO: $25,000$50,000 DEDUCTIBLE:

OTHER COVERAGE:

DEDUCTIBLE:

PRIOR INSURANCE HISTORY FOR THE PAST 3 YEARS:

POLICY PERIOD LIABILITY LOSSES LOSSES
(mm/yy) COMPANY NAME NUMBER AMOUNT NUMBER AMOUNT
TO
TO
TO

*If any prior losses, please provide a copy of currently valued loss runs.

CONTACT NAME: PHONE:

AGENT:         FAX:

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