Business and Commercial vehicle Policy

A Business Auto Policy can provide the necessary vehicle coverage required for commercial vehicles. It includes coverage for bodily injury, property damage, physical damage, medical payments, and uninsured motorist. Many endorsements are available to tailor this type coverage to meet your requirements.

business and commercial VEHICLES QUOTATION REQUEST FORM

REMINDER - Fields marked with an asterisk( * ) require a response.

Contact Information

Contact Person's Name:*

Telephone #, including area code:*

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Fax #, including area code:*

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E-Mail address:*

Business Name:*

Business Address:*

Business Address (other; e.g., suite)

City, State, and Zip Code of business:*

Business Information

Year business started:*

How many years of experience does the owner of your business have in your industry? *

Is this for a one-time event or seasonal business?*

Yes No

What is your business legal entity?*

What industry is your company in?*

Detailed description of your business:*

# of Active Owners and/or Partners:*

# of Full Time Employees:*

# of Part Time Employees:*

# of Independent Contractors:*

Coverage Information

Is this quote for vehicles (trucks, vans and/or autos) used in your business? *

Yes No

Select the desired Liability Insurance limit:* (Choose either "Split" or "Combined" limits)

Do you want physical damage coverage (both Comprehensive and Collision) quoted for vehicles with a value shown on the schedule below ? *

Yes No

If yes, choose a set of comprehensive and collision deductibles: *

Vehicle Schedule: (Complete only if requesting a commercial auto quote)

Vehicle #1

Model Year
Vehicle Make
Vehicle Model
Gross Weight
Market Value

Vehicle #2

Model Year
Vehicle Make
Vehicle Model
Gross Weight
Market Value

Vehicle #3

Model Year
Vehicle Make
Vehicle Model
Gross Weight
Market Value

Vehicle #4

Model Year
Vehicle Make
Vehicle Model
Gross Weight
Market Value

Do you have additional vehicles to list?

Yes No

If yes, please list additional vehicles in the additional vehicle section (provide year, make, model, gross vehicle weight and current value) *

Additional Vehicle Section:

Would you like to include "Employee Non-Owned Auto and Hired Auto liability coverage in your quote?

Yes No

Do you require any special insurance filings such as PUC, ICC, or MCP65? *

Yes No

If yes, indicate which filing is required:

Driver Schedule: * (Please list all drivers, including partners, co-owners, drivers in your household, occasional drivers, etc.)

Driver #1

Driver's First Name
Driver's Birth Date
California Driver License Number
Number of tickets in last 3 years:
Number of Major tickets in last 5 years:
Number of Accidents in last 3 years:

Driver #2

Driver's First Name
Driver's Birth Date
California Driver License Number
Number of tickets in last 3 years:
Number of Major tickets in last 5 years:
Number of Accidents in last 3 years:

Driver #3

Driver's First Name
Driver's Birth Date
California Driver License Number
Number of tickets in last 3 years:
Number of Major tickets in last 5 years:
Number of Accidents in last 3 years:

Driver #4

Driver's First Name
Driver's Birth Date
California Driver License Number
Number of tickets in last 3 years:
Number of Major tickets in last 5 years:
Number of Accidents in last 3 years:

Do you have additional drivers to list?

Yes No

If yes, please list additional drivers in the additional driver section (provide first name, date of birth, CA driver license number, the number of tickets in the past 3 years, the number of major tickets in the past 7 years, and the number of accidents in the past 3 years). *

Additional Driver Section:

Would you like a quote for a different type coverage? Click on the quotation Request button at the bottom of this from.

Claims History

Has your business had any claims in the past 3 years for the type of insurance being quoted?*

Yes No

If yes, please provide details of "all claim occurrences in the past 3 policy years," include dates, amounts paid by your insurance company, and description of the claim (include what happened and any corrective actions taken to prevent a reoccurrence of a similar claim).

Congratulations. You have reached the end of our form. If you'd like to submit a comment, provide an explanation of any information you've provided on this form, or give information on additional coverage needed, please do so in the space below. We also invite you to contact us by telephone or fax with more information about your business or your insurance needs.

After you have entered all relevant comments, please click the submit button. Thank you for completing this form, we'll do our best to provide you with a timely quote.

Business and Commercial vehicle Policy

business and commercial VEHICLES QUOTATION REQUEST FORM

Contact Information

Business Information

Coverage Information

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