Business Information
Date business was established:
Will this auto be used for:	Business only Business/personal Personal only
Are the number of jobsites, deliveries, or errands per day less than or equal to two?	Yes No
Were there any bankruptcies or unresolved tax liens in the past 35 months?	Yes No
Did you have 6 months or prior insurance without lapse?	Yes No
Did you have 12 months or prior insurance without lapse and were the "BI" bodily injury liability limits on your policy at or above 50/100 (50,000/100,000) or if "CSL" combined single limit at above 100 (100,000)?	Yes No
Driver Information
Number of drivers:	1 2 3 4
Driver 1 name:
Age:
Marital status:	Single Married
Years driving:
List any at-fault accidents ro moving violations withint the past 3 years (include dates):
Driver 2 name:
Age:
Marital status:	Single Married
Years driving:
List any at-fault accidents ro moving violations withint the past 3 years (include dates):
Driver 3 name:
Age:
Marital status:	Single Married
Years driving:
List any at-fault accidents ro moving violations withint the past 3 years (include dates):
Driver 4 name:
Age:
Marital status:	Single Married
Years driving:
List any at-fault accidents ro moving violations withint the past 3 years (include dates):
Vehicle Information
Type of vehicle:	Commercial auto (truck/van) Private passenger car
Year:
Make:
Model:
Vehicle Identification Number (VIN):
Cost new:
Address where garaged:
City:
State:
Zip code:
Is this vehicle principally operated by employees?	Yes No
Coverages
Do you want additional no-fault coverage?	Yes No
Liability limits:	$25,000 $35,000 $50,000 $100,000 $250,000 $300,000 $500,000 $1,000,000 Other
Uninsured motorist:	None $25,000 $35,000 $50,000 $100,000 $250,000 $300,000 $500,000 $1,000,000
Underinsured motorist:	None $25,000 $35,000 $50,000 $100,000 $250,000 $300,000 $500,000 $1,000,000
Unstacked uninsured motorist	Yes No
Unstacked underinsured motorist:	Yes No
Comprehensive deductible:	None 50 100 250 500 1,000
Collision deductible:	None 50 100 250 500 1,000
Towing and labor:	Yes No
Rental reimbursement:	Yes No
Rating Information
Gross vehicle weight:	Light (0 - 10,000 lbs) Medium (10,001 - 20,000 lbs) Heavy (20,001 - 45,000 lbs) Extra heavy (over 45,000 lbs)
How many axles?	One Two Three or more
Radius driven:	0 - 50 miles 51 - 200 miles 201 and over
Select business use:	Service Retail Commercial
Describe use of vehicle:
Choose one:	Utility Tractor Trailer None
Choose code class:	Contractors Food delivery Specialized delivery-time critical Waste disposal Farmer Dump and transit mix Trucker-transport goods All others
If a bus or van, total number of passengers:
Is there more than one vehice besides the one described above that is the same?	Yes No
If you have more than one vehicle with different descriptions/uses for your business, please fill out a separate form and submit to us separately.
Current insurance carrier:
Effective date:
Premium paid:
Do you have quotations from other companies?	Yes No
Would you like a quote from us for the same coverage for easy comparison?	Yes No
Who is the insurance company?
What was the price quoted?
How did you hear about us?	-choose one- Yellow Pages Newspaper Magazine Billboard Office Sign Radio TV Brochure Search Engine Mailer Referral
Additional Comments:

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