Person:
Telephone #: / Fax#:
PUBLIC AUTO QUICK QUOTE – For 4 or Less Vehicles Only
1. Name:2. Address:
Garaging Address ( if different)
3. Social Security # or FEIN:
4. Applicant is: Individual Partnership Corporation Other :
5. Current Carrier:
6. Expiration of Current Policy:
7. Business Description:
8. Years experience in this business:
9. Maximum Radius of Operations:
10. Routes Followed & Cities Entered:
11. DOT#: / Do you have an MC #? Yes No If Yes, list Docket Number:
12. 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?
13. Any Airport Exposure? Yes No If Yes, percentage:
Please list airports entered:
Schedule of Drivers
Name
/ Date Of Birth / State & Lic # / 3 Yr Acc & Viol History / Exp driving similar vehicle / Date of hire1.
2.
3.
4.
5.
Vehicle Schedule
/Year
/Trade Name
/Type of Vehicle
/GVW / Seat Cap
/Length of Limo in Inches
/Current Value
/Max 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 Yr1 Yr Prior
2 Yr Prior
Coverages
/Limits of Liability
Bodily Injury Liability / Property Damage LiabilityUninsured Underinsured Motorist Liability
Medical Payments Personal Injury Protection
Specified Cause of Loss Comprehensive
Collision
Other: / $ CSL
$ CSL $ CSL
$ Each Person
$ Deductible
$ Deductible
Prior Employer Info (New Ventures Only)
Employer
/Dates of Employment
/Type of Unit
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Remarks:
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