Commercial Auto Form

General Information

Name of Business*

Contact Name*

Street Address*

City*

State:

ZIP:

Phone*

(

)

Email

Fax

(

)

Best time to call

AM

PM

Current Insurance Company (not agency)

Company Name
Policy Exp. Date
Current Premium

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #1	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Vehicle #1

If vehicle is kept at an address other than that listed above, please indicate

Location City:

State:

Zip:

Full Coverage:

yes

no

Seasonal Use:

yes

no

- Used:

From

to

Vehicle Used for:

Season Used:

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #2	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Vehicle #2

If vehicle is kept at an address other than that listed above, please indicate

Location City:

State:

Zip:

Full Coverage:

yes

no

Seasonal Use:

yes

no

- Used:

From

to

Vehicle Used for:

Season Used:

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #3	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Vehicle #3

If vehicle is kept at an address other than that listed above, please indicate

Location City:

State:

Zip:

Full Coverage:

yes

no

Seasonal Use:

yes

no

- Used:

From

to

Vehicle Used for:

Season Used:

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #4	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Vehicle #4

If vehicle is kept at an address other than that listed above, please indicate

Location City:

State:

Zip:

Full Coverage:

yes

no

Seasonal Use:

yes

no

- Used:

From

to

Vehicle Used for:

Season Used:

Liability

Class of Business:
	Retail	Wholesale	Retail or Wholesale
	Service	Truckers	Food Concessions

Limits Requested

$1,000,000

Describe any claims you had in the past 3 years

Additional Comments

Please give any additional comments about the coverage you desire

Commercial Towing & Recovery Quote Form