Commercial Auto Application

Commercial Auto Application - (Page: 1 of 5)

Please complete the form below and click the submit button to complete the application.

Fields marked with (*) are required fields.

Browser Compatibility

Application works only in Microsoft Internet Explorer - Compatability View and Mozilla Firefox, does not work in Google Chrome

Agent Information

Agency*

Agent Name*

Agent Phone*

Fax*

Email Address*

Would you like the quote sent?* Fax Email

Policy Information

Legal Entity*

Named Insured*

Owner Name*

Contact Name*

Mailing Address*

City*

State*

Zip Code*

Predominant State*

Customer Phone*

Business Description*

Effective Date*

Expiration Date*

Year business established/acquired by current owner?*

Current Carrier*

Current Premium*

Loss History: Have there been any claims or loss occurrences in the last 3 years?* Yes No

Commercial Auto Application - (Page: 2 of 5)

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Fields marked with (*) are required fields.

Vehicle Schedule

Does this policy have 5 or more self propelled vehicles?* Yes No

Vehicle 1

Garaging Street* Garaging City* State* Zip Code* Year* Make/Model* VIN* Cost New

Add a second vehicle.

Add a third Vehicle.

Add a fourth vehicle.

Add a fifth vehicle.

Commercial Auto Application - (Page: 3 of 5)

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Fields marked with (*) are required fields.

Total Number of Drivers*

Driver List

Driver 1

First Name* Middle Name Last Name* Date of Birth* License Number* Age* Sex* State* Comm. MVR # Major Violations* Other Violations

Add another driver.

Commercial Auto Application - (Page: 4 of 5)

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Fields marked with (*) are required fields.

Commercial Auto Application - (Page: 5 of 5)

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Fields marked with (*) are required fields.

Attachments

Please attach any additional documents needed for your submission, click the folder below to select one or more files.

Commercial Auto Application - (Page: Review)

Your application has not been submitted yet. Please review all of your answers below and

click the submit button at the bottom of this page to complete your application

Please review all information.

Agency

Agent Name

Agent Phone

Fax

Email Address

Would you like the quote sent?

Policy Information

Legal Entity:

Named Insured

Mailing Address

City

State

Zip Code

Predominant State:

Customer Phone

Business Description

Effective Date:

Expiration Date:

Year business established/acquired by current owner?

Loss History: Have there been any claims or loss occurrences in the last 3 years?

Does this policy have 5 or more self propelled vehicles?

Vehicle 1

Garaging Street

Garaging City

State

Zip Code

Year

Make/Model

VIN

Cost New

Vehicle 2

Add a second vehicle.

Garaging Street

Garaging City

State

Zip Code

Year

Make/Model

VIN

Cost New

Add a third Vehicle.

Garaging Street

Garaging City

State

Zip Code

Year

Make/Model

VIN

Cost New

Add a fourth vehicle.

Garaging Street

Garaging City

State

Zip Code

Year

Make/Model

VIN

Cost New

Add a fifth vehicle.

Garaging Street

Garaging City

State

Zip Code

Year

Make/Model

VIN

Cost New

Total Number of Drivers

First Name

Middle Name

Last Name

Date of Birth

License Number

Age

Sex

State

Comm. MVR

# Major Violations

Other Violations

Add another driver.

First Name

Middle Name

Last Name

Date of Birth

License Number

Age

Sex

State

Comm. MVR

# Major Violations

Other Violations

First Name

Middle Name

Last Name

Date of Birth

License Number

Age

Sex

State

Comm. MVR

# Major Violations

Other Violations

Add another driver.

First Name

Middle Name

Last Name

Date of Birth

License Number

Age

Sex

State

Comm. MVR

# Major Violations

Other Violations

Add another driver.

First Name

Middle Name

Last Name

Date of Birth

License Number

Age

Sex

State

Comm. MVR

# Major Violations

Other Violations

Liability

Liability Options

Limits

Medical Payments

Medical Payments Options

Limits

Uninsured Motorist

Limits

Comprehensive

Limits

Specified Causes

Limits

Collision

Collision Options

Limits

Towing

HIRED LIABILITY - EXCES

State

Not Used in Motor Carrier Ops

Excess Cost of Hire

Used in Motor Carrier Ops

Excess Cost of Hire

Hired Liability - Primary

NON-OWNED LIABILITY

State

Number of Employees

Employee Extension

Social Service Agency

Number of Volunteers

Volunteer Extension

If regular use by more than 50% of employees, input the premium

Drive Other Car

Rental Reimbursement

Certain Individual As Insured

Tapes and Records

Intl DIC & Excess Liability

Orig Equip Manufacturer Part

Pollution Buyback

Pollution Buyback - NY

Repossessed Auto Liability

Repossessed Auto Comprehensive

Repossessed Auto Specified COV

Repossessed Auto Collision

BAP Extension

Auto Coverage Plus

Captcha

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Commercial Auto Application - (Complete)

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