Commercial Auto Quote Form
Name:
Business Name:
Street Address:
City & Zip:
Telephone:
E-Mail Address:
Fax:
Mobile:
Best Time to Call:
Years in Business:
Vehicle Type:
>
Please Select One
Pickup, 1/2 Ton or less, 2 WD
Pickup, 1/2 Ton or less, 4 WD
Pickup over 1/2 Ton, 2 WD
Pickup over 1/2 ton, 4 WD
Utility w/o Bucket
Step Van, GVW 0-10,000
Step Van, GVW 10-18,000
Flat Bed, GVW 0-18,000
Flat Bed, GVW 18-26,000
Flat Bed, GVW 26-53,000
Stake Bed
Dump
Boom
Bucket
Liability Limit:
>
100,000
300,000
500,000
1,000,000
2nd Vehicle Type:
>
Please Select One
Pickup, 1/2 Ton or less, 2 WD
Pickup, 1/2 Ton or less, 4 WD
Pickup over 1/2 Ton, 2 WD
Pickup over 1/2 ton, 4 WD
Utility w/o Bucket
Step Van, GVW 0-10,000
Step Van, GVW 10-18,000
Flat Bed, GVW 0-18,000
Flat Bed, GVW 18-26,000
Flat Bed, GVW 26-53,000
Stake Bed
Dump
Boom
Bucket
Current Carrier:
3rd Vehicle Type:
>
Please Select One
Pickup, 1/2 Ton or less, 2 WD
Pickup, 1/2 Ton or less, 4 WD
Pickup over 1/2 Ton, 2 WD
Pickup over 1/2 ton, 4 WD
Utility w/o Bucket
Step Van, GVW 0-10,000
Step Van, GVW 10-18,000
Flat Bed, GVW 0-18,000
Flat Bed, GVW 18-26,000
Flat Bed, GVW 26-53,000
Stake Bed
Dump
Boom
Bucket
Policy Exp. Date:
Year, Make, Model, $Value:
Contractor's License Type:
2nd, Year, Make, Model, $Value:
Any Claims last 3 yrs?
>
No
Yes
3rd, Year, Make, Model, $Value:
Debris Hauled for Others?
>
No
Yes
Trailer Hitch?
>
No
Yes
Use of Vehicle:
>
Please Select One
Business Only
Business/Pleasure
Annual Payment Preference:
>
Please Select One
Full Pay
Deposit + 2 payments
Deposit + 6 payments
Deposit + 9 payments
Describe the Type of Work you do:
