Proposal: Commercial/Business Auto
 
 
A. Name:
Address 1:
Address 2:
City: State: Zip:
Phone: Fax:
       
     
B. Liability Insurance: 
1 Million 2 Million Other
C. Medical Payments:
Included Excluded
D. Uninsured Motorists:
Same as Liability Other
E. Comprehensive:
Deductible Excluded
 
     
F. Collision:
Deductible Excluded
G. Non-owned Auto Liability:
Yes No # of Employee's
H. Hired Auto Liability:
Yes No Annual Cost of Hire($):
         
 
Driver(s)
Name DOB License #  
 
 
Vehicle Schedule:
Year Make/Model GVW Radius Cost New Garaging Zip
 
 
     
K. Do you haul goods for others?:
Yes No
L. Current Insurer:
Policy #:
M. Any claims the past 5 years?:
Yes No
  If yes, explain:
Date Description of Accident Amount Paid Amount Reserved
         
     
N. Description of your operations:
     

 
 
 
 
License #: 0578496
Copyright Vicencia & Buckley Insurances Services Inc.
The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.
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