Commercial Vehicle Insurance

Owner’s Name:

Company Name:

Street Address:

City & Zip:

Phone:

Fax:

Email:

Garaging address if different from above:

Are you currently insured?:

If no, please state reason for applying:

If yes, who is your current insurance carrier?:

Expiration date of current policy:

Do you have any claims in the past 3 years?

Is the vehicle registered under your personal name or business name?

Type of business (sole proprietorship, partnership, corporation):

Describe in detail nature of operations of the business:

Number of years in business:

How many drivers does the company employ?

How many vehicles does the company own?

Complete For Each Driver

Driver’s Complete Name:	Driver’s Date of Birth:	Driver’s Marital Status:	Driver’s License Number:	How many years have you been licensed?	What state are you licensed in?	How many accidents do you have in the past 3 years?	How many tickets do you have in the past 3 years?

Complete For Each Vehicle

Vehicle Model Year:	Make:	Model:	Type of Vehicle:	Vehicle Identification Number:	What is the stated current value of the vehicle?	Describe any special equipment, its value and serial number:	Describe in detail how this vehicle is used in the course of the business:

Are there any additional trailers?

If so, what are the makes, models, values and identification numbers?

What is radius of operations (miles)?

Complete for desired coverages by indicating limits of insurance:

Business Auto Limits of Liability desired:

Uninsured Motorist:

Medical Payment:

Comprehensive Deductible:

Other

Collision Deductible:

Other

Do you have any hired/non-owned Autos?

Any State or Federal filings required?

Tell us more about your Business: