* # of vehicles:
* Make, Model, Year, and ownership of all vehicles to be insured (example: 1996 Chevy Express 2500 leased):
* Zip code(s) of where the vehicle is parked at night:
* Number of miles you drive from your location on a regular basis:
* Primary use of the vehicle:
* Year business started:
Profit or nonprofit
profit
non-profit
What is your business legal entity?
Corporation
S Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Sole Proprietorship
Limited Partnership
Professional Corporation
Nonprofit Corporation
What industry is your company in?
SELECT --->
OFFICE >>>
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Chiropractors' Offices
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Interior Designers/Decorators
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Publishing Offices
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SERVICES >>>
Appliance Installation
Appliance Repair
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Printing (Commercial)
Printing (Instant Print & Duplic.)
Radio & TV (Retail & Repair)
Rehabilitative Services
Shoe Repair
Tailors
Taxidermists
Tour Services
Tow Trucks
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Other Service-based Industry
MANUFACTURING >>>
Candy & Other Confec. Prod. Mfg.
Canned Specialties Mfg.
Computer Equipment Mfg.
Electronics Mfg.
Food Products Mfg.
Household Audio & Video Equip. Mfg.
Metal Mfg.
Metal Working Job Shops
Microbreweries Mfg.
Office and Store Fixtures
Partition and Shelves Mfg.
Office Machines Mfg.
Plastics Machines Mfg.
Radio and TV Comm. Equip. Mfg.
Tool and Die Patterns and Mold Mfg.
Other Manufacturing-based Industry
CONTRACTORS >>>
Janitorial Services
Air Conditiong Contractors
Cabinet Building & Installation
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Carpet Laying Installation
Ceramic Tile Installation
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Drywall Installation Contractors
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Heating Contractors
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Roofers
Telephone Equipment Installation
Other Contracting-based Industry
RETAIL/WHOLESALE >>>
Appliance Stores
Automobile Dealerships
Automobile Parts
Bath Shops
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Beauty Supplies
Books/Magazines Retail
Cameras & Supplies
Candy/Nut & Confectionery Stores
Carpet Retail
Clocks
Dance Clubs
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Florists/Garden Shops
Gift/Souvenir Shops
Greeting Cards
Hardware Stores
Health Food Stores
Hearing Aids
Hobby Shops & Model Stores
Ice Cream Parlors
Optical Goods
Pet Shops & Pet Supplies
Picture Frames
Plumbing Supplies
Restaurant
Shoes
Sporting Goods
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Toys
Trophies
T-shirt Shops
Video Tape Stores
Other Retail/Wholesale Industry
OTHER >>>
Airboat Related
Alarms/Guards
Apartments
Churches & Synagogues
Coastal Property
Habitat
Horse Related
Import/Export
Marine
Non-Profit Organization
Oil & Gas
Parks
Water Related
* How many years of experience does the owner of your business have in your industry?
* Detailed description of the nature of business:
Are you currently insured?
Yes No
If yes, what company?
Expiration Date:
What is the approximate amount you pay for commercial auto insurance now?
* How many claims have you filed in the past 3 years?
Name, Birth date, License Number and License State of each driver of the vehicles: (Example: Joe Smith, 060168, 7865423, CA)
What comprehensive deductible do you want?
Not Sure
$50
$100
$250
$500
$1000
What collision deductible do you want?
Not Sure
$50
$100
$250
$500
$1000
What limit for Bodily Injury and Property Damage Liability do you want?
Not Sure
$50,000/Occurrence
$100,000/Occurrence
$250,0000/Occurrence
$500,000/Occurence
$1,000,000/Occurrence
* Date or period coverage should start:
* # of Active Owners and/or Partners:
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* # of Full Time Employees:
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* # of Part Time Employees:
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* # of Sub-Contractors:
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