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Commercial Auto Insurance Quotes
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(703) 986-0468
Commercial Auto Insurance Quotes
Step
1
of
8
12%
General Information
Name of Insureds
*
Business Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the garaging address the same as the business address?
*
Yes
No
Garaging Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Phone
*
Fax Number
Email Address
*
Business Tax ID#
*
# of drivers to be included
*
Has insured had continuous coverage for at least one year?
*
Yes
No
President/CEO
First Name
Last Name
Suffix
Involved with daily business operations?
Yes
No
Date of Birth
MM slash DD slash YYYY
Home Address
How Did You Hear About Us?
Please check all that apply:
Search Engine
Social Network
Forum/Blog
Advertisement
Family or Friend
Coworker
Other
Other:
Current Commercial Auto Insurance Information
Company Name (not agency)
Policy Expiration Date
MM slash DD slash YYYY
Premium Amount $
Term
6 Months
1 year
Other
Other
Underwriting Questions
Does the insured have a General Liability Insurance or Business Owner's Policy?
Select One
Neither
General Liability Insurance
Business Owners Policy
Year Current Business Was Established
Number of Additional Insureds
Number of Waiver of Subrogation
Policy Filings
Are any state or federal filings required?
Yes
No
Do we insure all commercial vehicles the insured owns?
Yes
No
Do we insure all vehicles that the insured uses in their business?
Yes
No
Filing Types
Federal
Yes
No
MCS90
Yes
No
Federal Cargo (BMC-34)
Yes
No
State
Select
0
1
2
3
4
5
6
7
8
9
State Cargo (Form H)
Select
0
1
2
3
4
5
6
7
8
9
Other: (0-9)
Select
0
1
2
3
4
5
6
7
8
9
Desired Coverage Information
Liability Amount (csl)
Select One
$300,000
$350,000
$500,000
$600,000
$1,000,000
Uninsured Motorist - Bodily Injury (csl)
Select One
None
$25,000
$50,000
$60,000
$100,000
$250,000
$350,000
$500,000
$1,000,000
Uninsured Motorist - Property Damage
Yes
No
Medical
Select One
None
$500
$1,000
$2,000
$5,000
Motor Trucking Cargo
Yes
No
Downtime/Rental (if available)
Yes
No
Roadside Assistance (if available)
Yes
No
Hired Auto
Yes
No
Non-Owned Auto
Yes
No
Comprehensive Deductible
Yes
No
If "Yes," Select One
Select
$250
$500
$1,000
Collision Deductible
Yes
No
If "Yes," Select One
Select
$250
$500
$1,000
Vehicle Information
You can list up to 5 vehicles on this form. Reuse this form multiple times for additional vehicles.
# of Vehicles
*
1
2
3
4
5
Auto #1
Year
Make
Model
VIN #
Gross Vehicle Weight (lbs.)
Cost New $
Radius (in miles, one way)
Vehicle Use
Select One
Commercial
Service
Retail
Is this vehicle garaged at a location other than mailing/business address?
Yes
No
Please describe in detail what the vehicle is used for.
If commodity is hauled, please explain.
Auto #2
Year
Make
Model
VIN #
Gross Vehicle Weight (lbs.)
Cost New $
Radius (in miles, one way)
Vehicle Use
Select One
Commercial
Service
Retail
Is this vehicle garaged at a location other than mailing/business address?
Yes
No
Please describe in detail what the vehicle is used for.
If commodity is hauled, please explain.
Auto #3
Year
Make
Model
VIN #
Gross Vehicle Weight (lbs.)
Cost New $
Radius (in miles, one way)
Vehicle Use
Select One
Commercial
Service
Retail
Is this vehicle garaged at a location other than mailing/business address?
Yes
No
Please describe in detail what the vehicle is used for.
If commodity is hauled, please explain.
Auto #4
Year
Make
Model
VIN #
Gross Vehicle Weight (lbs.)
Cost New $
Radius (in miles, one way)
Vehicle Use
Select One
Commercial
Service
Retail
Is this vehicle garaged at a location other than mailing/business address?
Yes
No
Please describe in detail what the vehicle is used for.
If commodity is hauled, please explain.
Auto #5
Year
Make
Model
VIN #
Gross Vehicle Weight (lbs.)
Cost New $
Radius (in miles, one way)
Vehicle Use
Select One
Commercial
Service
Retail
Is this vehicle garaged at a location other than mailing/business address?
Yes
No
Please describe in detail what the vehicle is used for.
If commodity is hauled, please explain.
Loss Information
How many losses have there been in the last 3 years?
If any, please explain:
Driver Information
(include all licensed drivers in your business)
# of Drivers
*
1
2
3
4
Driver #1
Driver's Name
Drivers License #
Drivers License State
Years Licensed
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Marital Status
Married
Single
Completed Drivers Ed Course in Last 3 Years?
Yes
No
Completed Accident Prevention Course in Last 3 Years?
Yes
No
SR22 Filing
Yes
No
FR44 Filing
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Driver #2
Driver's Name
Drivers License #
Drivers License State
Years Licensed
Job Title
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Marital Status
Married
Single
Completed Drivers Ed Course in Last 3 Years?
Yes
No
Completed Accident Prevention Course in Last 3 Years?
Yes
No
SR22 Filing
Yes
No
FR44 Filing
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Driver #3
Driver's Name
Drivers License #
Drivers License State
Years Licensed
Job Title
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Marital Status
Married
Single
Completed Drivers Ed Course in Last 3 Years?
Yes
No
Completed Accident Prevention Course in Last 3 Years?
Yes
No
SR22 Filing
Yes
No
FR44 Filing
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Driver #4
Driver's Name
Drivers License #
Drivers License State
Years Licensed
Job Title
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Marital Status
Married
Single
Completed Drivers Ed Course in Last 3 Years?
Yes
No
Completed Accident Prevention Course in Last 3 Years?
Yes
No
SR22 Filing
Yes
No
FR44 Filing
Yes
No
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Driver History
List ANY convictions for ANY driver convicted of moving traffic violations in the past 5 years.
Driver
Date
Conviction Type
$ Fines
Speed Over Limit (mph)
Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
Was License Suspended?
Was License Revoked?
Was Driver Convicted of DUI for Alcohol?
Was Driver Convicted of DUI for Drugs?
Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
$ Cost
$ Fines
Were There Injuries?
Was Driver At Fault?
Additional Comments
Please give any additional comments you feel appropriate for this quotation.
If you have additional information where there was not enough fields above, please enter them here.
Phone
This field is for validation purposes and should be left unchanged.
Δ
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