Commercial Auto Company Name of Company / Church / School Address Phone Email Present Company? Renewal Date? Expiring Premium? Why Shopping? Please Choose One Individual Corporation Partnership Join Venture LLC Federal I.D. Number: Years Organized? Years At This Address? Claims or Losses Claim #1: Date Claim #1: Type of Claim Claim #1: Amount Paid? Claim #2: Date Claim #2: Type of Claim Claim #2: Amount Paid? Claim #3: Date Claim #3: Type of Claim Claim #3: Amount Paid? Vehicle Vehicle #1: Model Vehicle #1: Type Vehicle #1: Year Vehicle #1: Number of Passengers Vehicle #1: Use Vehicle #1: Cost New / Used Vehicle #1: Garaging Location Vehicle #1: Coverages Vehicle #1: Liability Vehicle #1: Medical Vehicle #1: Comprehensive Vehicle #1: Collision Vehicle #1: Uninsured Motorist Vehicle #1: Towing / Labor Vehicle #1: Vin # Vehicle #2: Model Vehicle #2: Type Vehicle #2: Year Vehicle #2: Number of Passengers Vehicle #2: Use Vehicle #2: Cost New / Used Vehicle #2: Garaging Location Vehicle #2: Coverages Vehicle #2: Liability Vehicle #2: Medical Vehicle #2: Comprehensive Vehicle #2: Collision Vehicle #2: Uninsured Motorist Vehicle #2: Towing / Labor Vehicle #2: Vin # I understand that I am requesting an Insurance Proposal based on the information I am providing. I am requesting the Limits and Coverage as indicated. All information is true and accurate to the best of my knowledge. I do understand that this is an estimate and the premium could change based on reports and additional information obtained by the insurance carrier. I give permission to check all public information available as necessary to provide a Proposal I understand that I am requesting an Insurance Proposal based on the information I am providing. I am requesting the Limits and Coverage as indicated. All information is true and accurate to the best of my knowledge. I do understand that this is an estimate and the premium could change based on reports and additional information obtained by the insurance carrier. I give permission to check all public information available as necessary to provide a Proposal. . *
