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  Commercial Auto Insurance Quote
Full Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Website Address:
Day Telephone:  
Eve Telephone:  
Fax:  
Number of years at current address:  
If less than 3 years, please provide prior address(es):
(1) Street Address:   (2) Street Address:
     City, State, Zip:        City, State, Zip:
 
 Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)
Policy Expiration Date:    Premium Amount:
Term:      How long with current insurance?
 
*Please fax or email a copy of your current policy and 3 year loss runs.
 
 Vehicle Information               (Please list all vehicles owned & leased.)
Vehicle 1:  
Year:    Make/Model:   Vin #:
Yearly Mileage:   Mileage:
Usage:
 
Vehicle 2:  
Year:    Make/Model:   Vin #:
Yearly Mileage:   Mileage:
Usage:
 
Vehicle 3:  
Year:    Make/Model:   Vin #:
Yearly Mileage:   Mileage:
Usage:
 
Vehicle 4:  
Year:    Make/Model:   Vin #:
Yearly Mileage:   Mileage:
Usage:
 
*If more than 4 vehicles, please email or fax a list of all vehicle make and models.
 
Any Custom equipment on vehicles?
(if YES, give their value &
indicate which vehicle):  
Debris hauled for others?:     No
Trailer Hitch?:     No                 Class of Business:
 
 Coverage Information
Liability limits for bodily injury & property damage:  
Uninsured Motorist Bodily Injury:  
 
 Deductibles
 
Comp & Collision
 
Vehicle #1  
Vehicle #2  
Vehicle #3  
Vehicle #4  
     
 Driver's Information
Driver 1:
Name: Sex: F
DOB: Married? No
Year Licensed: Occupation:
       
Driver 2:
Name: Sex: F
DOB: Married? No
Year Licensed: Occupation:
       
Driver 3:
Name: Sex: F
DOB: Married? No
Year Licensed: Occupation:
       
Driver 4:
Name: Sex: F
DOB: Married? No
Year Licensed: Occupation:
       

 

 Accidents / Violations in the last 5 years?
 
Driver 1
Driver 2
Driver 3
Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Chargeable Accident Cost($):
Major violations - drunk driving, reckless, hit and run, etc.
 
 Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.

We will not distribute information to other parties other than for insurance underwriting purposes.

By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree - By checking this box, you agree to release us from any liability should this information be accidentally viewed by others and you specifically agree that you are permitting any records to be run and reviewed in order to provide you with the best quotation including but not limited to accident loss history, motor vehicle record and credit.

 

 

 

(p) (828) 258-8030 ∙ (f) (828) 258-8030
(e) tony_johnson_agency@nationwide.com