Commercial Auto Quote

Last Name
First Name
M. I.
Company Name
Physical Address
City
State
Zip
County
Mailing Address (if different)
City
State
Zip
County
Email
Web site
Home Phone
Cell Phone
Work Phone
Description of Business Operations
Present Insurance Company
Renew Date
Car One
Year
Make
Model
Vin #
Radius of Operation		Please Select Under 50 Miles 50-100 Miles 100-200 Miles Over 200 Miles
Car Two
Year
Make
Model
Vin #
Radius of Operation		Please Select Under 50 Miles 50-100 Miles 100-200 Miles Over 200 Miles
Car Three
Year
Make
Model
Vin #
Radius of Operation		Please Select Under 50 Miles 50-100 Miles 100-200 Miles Over 200 Miles
Driver One
Driver Name
Relationship		Please Select Owner Employee
Date of Birth
Date when License Obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Moving Violations in the last 5 years		Please Select None 1 2 3 4 More
Please provide date and description of each violation
Has license ever been suspended or revoked?		Please Select Yes No
Claims, both “At-Fault” and “Not-At-Fault”in last 5 years		Please Select 0 1 2 3 4 More
Please provide a date, amount, and description of each accident
Driver Two
Driver Name
Relationship		Please Select Owner Employee
Date of Birth
Date when License Obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Moving Violations in the last 5 years		Please Select None 1 2 3 4 More
Please provide date and description of each violation
Has license ever been suspended or revoked?		Please Select Yes No
Claims, both “At-Fault” and “Not-At-Fault” in last 5 years		Please Select 0 1 2 3 4 More
Please provide a date amount, and description of each accident
Driver Three
Driver Name
Relationship		Please Select Owner Employee
Date of Birth
Date when License Obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Moving Violations in the last 5 years		Please Select None 1 2 3 4 More
Please provide date and description of each violation
Has license ever been suspended or revoked?		Please Select Yes No
Claims, both “At-Fault” and “Not-At-Fault” in last 5 years		Please Select 0 1 2 3 4 More
Please provide a date amount, and description of each accident
Liability Limit for All Cars
Bodily Injury		Please Select 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,00 300,000/300,000 300,000/500,000 Higher
Property Damage		Please Select 10,000 25,000 50,000 100,000 200,000 500,000 1M
Medical Payments		Please Select 1,000 2,000 3,000 4,000 5,000
Uninsured/Underinsured Motorist Bodily Injury		Please Select 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,00 300,000/300,000 300,000/500,000 Higher
PIP (Personal Property Protection)		$50,000 minimum NYS requirement
Additional PIP		Please Select 25,000 50,000 100,000
OBEL (Optional Basic Economical Loss)		Please Select 25,000 Waive
Add Umbrella/Business Catastrophe Liability Coverage?		Please Select 1M 2M 3M 4M 5M Not at this time
Car One
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40
Car Two
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40
Car Three
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40

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