QUESTIONNAIRE
ABOUT YOU
Company Name
Your First Name
Last Name
Email
Street Address
City
State
Country
Zip
Phone
Fax
ABOUT YOUR BUSINESS
Sole Proprietor Partnership Corporation LLC
Do you currently have Commercial Auto Insurance? Yes No If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Description of Business Operations:
Year Business Established
Number of Drives
Number of Company Vehicles
Liability Limits Desired $750,000 $1,000,000 $2,000,000 Not Sure
Uninsured Motorist Limit Desired $750,000 $1,000,000 $2,000,000 Not Sure
Have you had any claims in the past 3 years? Yes No If "Yes", briefly explain:
Vehicle Make
Vehicle Model
Vehicle Year
Vin#
Vehicle Type
Optional Coverage (check the ones you may want)
What is the best time to reach you? Morning Afternoon Evening
