Commercial Automobile Quote Form
Please
fill out as much information as possible. If you have any questions
about this form or filing a claim, please contact
us. |
| BUSINESS
INFORMATION |
| Name
of Business: |
|
| Contact
person: |
|
| All
locations of business: |
|
| Type
of business: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| Tax
Identification Number: |
|
| COVERAGES
REQUESTED |
|
Liability: |
|
|
Uninsured Motorist: |
|
|
Medical Payments: |
|
|
Specified Perils: |
|
|
Comprehensive Deductible: |
|
|
Collision Deductible: |
|
| NAME
OF EACH DRIVER, DATE OF BIRTH AND DRIVER LICENSE NUMBER |
Please
list name, date of birth, and drivers license numbers for all drivers: |
|
| Indicate
if any drivers have traffic violations or automobile accidents within
the last three years: |
|
| VEHICLE
DESCRIPTION #1 |
| Year :
|
Make :
|
Model:
|
| Serial
Number:
Cost New:
|
| Garaging
Location:
Radius of Use:
|
| Coverages
Desired: |
Liability
Medical
Payments
Uninsured
Motorist
Comprehensive
Collision |
| VEHICLE
DESCRIPTION #2 |
| Year :
|
Make :
|
Model:
|
| Serial
Number:
Cost New:
|
| Garaging
Location:
Radius of Use:
|
| Coverages
Desired: |
Liability
Medical
Payments
Uninsured
Motorist
Comprehensive
Collision |
| VEHICLE
DESCRIPTION #3 |
| Year :
|
Make :
|
Model:
|
| Serial
Number:
Cost New:
|
| Garaging
Location:
Radius of Use:
|
| Coverages
Desired: |
Liability
Medical
Payments
Uninsured
Motorist
Comprehensive
Collision |
| VEHICLE
DESCRIPTION #4 |
| Year :
|
Make :
|
Model:
|
| Serial
Number:
Cost New:
|
| Garaging
Location:
Radius of Use:
|
| Coverages
Desired: |
Liability
Medical
Payments
Uninsured
Motorist
Comprehensive
Collision |
| |
|
|
|
|
| Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
