Agency Name:
Person:
Telephone #: / Fax#:

COMMERCIAL AUTO QUICK QUOTE – For 4 or Less Vehicles Only ( >300 Miles or Cargo, complete Page 2)

1. Name: / Principal Owner:
2. Address:
Garaging Address (if different):
  1. Social Security # or FEIN:

  1. Applicant is: Individual Partnership Corporation Other :

  1. Date Business Started:
/ Date Coverage Desired:
  1. Current Premium:

  1. Description of Business:

  1. List Specific Commodities Hauled and % of each:

  1. List any Hazardous commodities Hauled:

  1. Maximum Radius of Operations:

  1. Routes Followed & Cities Entered:

  1. U.S. DOT #:

  1. Do Applicant have an MC #? Yes No If Yes, list Docket Number:

  1. Are State Filings Needed? Yes No If Yes, list State(s) and Auth # (if app)

Form E? Yes No Form H? Yes No Additional Filings?
  1. Does applicant own or operate any equipment over 10,000 GVW not listed in this application? Yes No

  1. Do applicant hire any equipment? Yes No Is so, what is your annual cost of hire?

Schedule of Drivers

Name

/ Date Of Birth / State & License # / 3 Yr Acc & Viol History / Exp Driving Similar Vehicles / Date of hire
1.
2.
3.
4.
5.

Vehicle Schedule

Year

/

Trade Name

/

Type of Vehicle

/

GVW / Seat Capacity

/

Current Value

/

Maximum Radius

1.
2.
3.
4.
5.

Prior 3 Year Carrier Information

Liability Carrier

/

Phys Dam Carrier

/

# Losses Liability

/

# Losses Phys Dam

/

Amount Paid

/

Driver Name

Last Yr
1 Yr Prior
2 Yr Prior

Coverages

/

Limits of Liability

Bodily Injury Liability / Property Damage Liability
Uninsured Underinsured Motorist Liability
Medical Payments Personal Injury Protection
Specified Cause of Loss Comprehensive
Collision
Other: / $ CSL Primary Non Trucking
$ CSL $ CSL
$ Each Person
$ Deductible
$ Deductible

Prior Employer Info (New Ventures Only)

Employer

/

Dates of Employment

/

Type of Unit

-
-

Remarks:

Supplement for Accounts Operating Over 300 miles and for Cargo Coverage

Percentage of Long Haul Operations, over 200 miles, to or from each City Group: (Please Indicate Specific Cities)

Zone 1 % / Zone 2 % / Zone 3 % / Zone 4 %
Balt. Washington
Los Angeles
Miami
New York City
Philadelphia / Atlanta
New Orleans
Boston
San Francisco
Chicago / Dallas
Hartford
Houston / Buffalo
Charlotte
Cincinnati
Cleveland
Denver
Detroit / Indianapolis
Jacksonville
Kansas City
Little Rock
Louisville
Memphis / Milwaukee
Minneapolis/St. Paul
Nashville
Oklahoma City
Omaha
Phoenix / Pittsburgh
Portland
Richmond
St. Louis
Salt Lake City
San Diego
Seattle / Remainder of Country

Radius of Operations

0 – 50 miles / 50 – 100 miles / 101 – 200 miles / 201 – 300 miles / 301 – 500 miles / 501 – 1000 miles / 1000 + miles
% / % / % / % / % / % / %
Five Most Common Hauls By Destination:
1.
2.
3.
4.
5.

Cargo Section

Limit: / Deductible:
Cargo Hauled / % / Maximum Value / Average Value

Cargo – Prior 3 Year Carrier Information

Carrier / # Losses / Amount Paid / Driver Name
Last Year
1 Yr Prior
2 Yr Prior

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