Commercial Auto Insurance

BUSINESS NAME

Doing Business As (Optional)

Business Website (Optional)

Do you have a USDOT Number?

Yes - I have a USDOT number No - and I will not have a USDOT number Not Yet - but I have applied/will apply for a USDOT number within 60 days

USDOT Number associated with your business:

FIRST NAME

MIDDLE NAME INITIAL

LAST NAME

Your Email

Date of Birth

What is the physical address of your primary business location?

Use business address as my mailing address

Yes No

Address Line 2

Zip Code

State

What Type Of Work Does Your Business Do?

What is the total number of business and residential units within the building you operate out of?

Do you have any employees?

Yes No

Estimated annual rental income:

Is It Just The Owners?

Yes No

How many employees do you have??

When did you start your business?

How is your business structured?

Is this vehicle used for business, personal or both?

Business Only Business & Personal Personal Only

Is there a loan/lease on this vehicle?

Yes, I have a loan Yes, I have a lease No

Do you need Comprehensive or Collision coverage to protect this vehicle in an accident or loss?

Yes No

Bodily Injury Liability Limit

Comprehensive Deductible

Collision Deductible

When do you want your policy to start?

What is your vehicle identification number (VIN)

What state is this vehicle's parking address in?

If you sold this vehicle today, how much would it be worth?

What's the year, make, and model?

What is the gross vehicle weight rating (GVWr) of the vehicle?

DRIVER FIRST NAME

DRIVER LAST NAME

Driver's License Number

Driver's License State

Date of Birth

Does this driver have a Commercial Driver's License (CDL)?

Yes No

How long has this driver had a Commercial Driver License (CDL)?

Select Less Than 1 Year At Least 1 Year But Less Than 2 Years 2 or More Years

Has this driver had an accident or violation in the past 3 years, or a conviction in the past 5 years?

Yes No

Which driver was involved in this incident?

What was the date of the incident?

What type of incident was it?

Select Accident Violation/Conviction Or Both

Was the driver at fault?

Yes No

Was the violation?

Was there another violation / conviction associated with this incident?

Yes No

Do you have or plan on applying for an operating authority from the Department of Motor Vehicles?

Yes No

Please enter your Department of Motor Vehicles UIN #:

Do you have any active Trailer Interchange Agreements?

Yes No

How many auto insurance claims did your business have in the last 3 years?

Do you provide any For Hire passenger transport operations?

Yes No

Do the owner(s) of this business have a combined majority ownership in any other transportation business?

Yes No

Do you provide any For Hire goods hauling operations?

Yes No

Where does your business operate?

Do clients visit your home as part of your business?

Yes Clients Visit My Home No Clients Don't Visit My Home

When was your last policy in effect?

Does your business own or lease any of the following?

Does your business use any vehicles that it does not own?

Yes No

Are you required to name a third party as an additional insured or loss payee on your policy?

Yes No

Do you need to add a bank or lender to your policy?

Yes No

How many other people or organizations do you need to add?

Do you need to add vendors to your policy?

Yes No

Do you need to add a grantor of franchise to your policy?

Yes No

Are you required to name a loss payee on your policy?

Yes No

Do you need to add an equipment lessor on your policy?

Yes No

Business Email

Business Phone Number

Extension Number

Primary owner's information In order to provide you with the best price possible, a soft credit score check will be completed using the primary owner's information. The soft credit score check will not impact the owner's credit score. Do You Agree

Yes No

COMMERCIAL AUTO