DRIVER INFORMATION
#1
(if more than two drivers, list in remarks)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION
#2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or call us at: 260-897-2161
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle Weight:
Cost New: $
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #1
COVERAGES:
Limits of Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #2:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle Weight:
Cost New: $
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE INFORMATION FOR UNITS #3-5:
(If none, Leave Blank)
VEHICLE #3
(List Year, Make, Model & Value)
VEHICLE #4
(List Year, Make, Model & Value)
VEHICLE #5
(List Year, Make, Model & Value)
VEHICLE #2 - #5
COVERAGES:
Limits of Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
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