DRIVER INFORMATION #1 (if more than two drivers, list in
remarks)
Name:
Birthdate:
Sex:
# Years
U.S. Auto License:
Number & Type
of Accidents within last 3 years:
Number & Type
of MINOR violations within last 3 years:
Number & Type
of MAJOR violations within last 3 years:
Daily commute in
ONE WAY miles:
Does Driver need an
SR22 FILING?
Yes No
Comments
or Remarks?
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years
U.S. Auto License:
Number & Type
of Accidents within last 3 years:
Number & Type
of MINOR violations within last 3 years:
Number & Type
of MAJOR violations within last 3 years:
Daily commute in
ONE WAY miles:
Does Driver need an
SR22 FILING?
Yes No
Comments
or Remarks?
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or call us
at: 952-469-0425
Year of
vehicle:
Make & Model:
Type (truck,
tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle
Weight:
Cost New:
$
Radius of
operation:
Value $:
List Special Equipment & Values (i.e.,
rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate
rating)
VEHICLE #1
COVERAGES:
Limits
of Liability:
$500,000 CSL
$750,000 CSL $1 Million CSL
Comprehensive & Collision:
NO Coverage $250
Deductible $500 Deductible $1000 Deductible
Do you want Medical
Coverage?
Yes No
Uninsured Motorists?
Yes No
COMMERCIAL VEHICLE
#2:
Year of
vehicle:
Make & Model:
Type (truck,
tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle
Weight:
Cost New:
$
Radius of
operation:
Value $:
List Special Equipment & Values (i.e.,
rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate
rating)
VEHICLE INFORMATION FOR UNITS
#3-5: (If none, Leave Blank)
VEHICLE #3 (List Year, Make, Model &
Value)
VEHICLE #4 (List Year, Make, Model &
Value)
VEHICLE #5 (List Year, Make, Model &
Value)
VEHICLE #2 - #5
COVERAGES:
Limits
of Liability:
$500,000 CSL
$750,000 CSL $1 Million CSL
Comprehensive & Collision:
NO Coverage $250
Deductible $500 Deductible $1000 Deductible
Do you want Medical
Coverage?
Yes No
Uninsured Motorists?
Yes No
Send my quotation
via:
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