Commercial Auto Insurance Request

Commercial Auto Insurance Request

Please complete as much as possible for the best results
List the Agents name you prefer to work with
If unknown, please enter "Lisa"
Your Company Name *
Or your name if the business is not currently established
Tax ID Number *
If available
Website
If available
Your Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Percentage of ownership *
If not 100%, please provide names of additional owners and their date(s) of birth:
Please describe your business and services you offer*
What is your Annual Gross Revenue*
How many vehicles do you wish to insure ? *
What are the vehicles used for? *
Are the vehicles registered in the business name?

YesNoIn process
Please provide for each vehicle: VIN, YEAR, MAKE, MODEL, VALUE*
Must have all of these to provide a quote.
Please describe any added permanently attached equipment and provide value to insure:*
If not applicable type None or n/a
Phone number *
Please enter a valid phone number.
Email*
example@example.com
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address if different
Any Additional Locations
If you are a towing company, please advise if you store client vehicles and the total lot value*
If not applicable type None or n/a
Are the vehicles kept at the business address?*

YesNo
If no, please provide address where stored when not in use (Garaged): *
If not applicable type None or n/a
Number of Full Time Employees*
Including owner and all officers
Number of Part Time Employees *
How many authorized drivers do you have (all owners must be included unless located in another country)? *
Please upload copies of all drivers licenses here:

May also send via email to DodgeAgency@outlook.com or text to: 817-776-0409 or 702-827-6007
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Current Insurance Provider*
If none, type n/a
Desired Effective Date*

MonthDayYear
Date
What Liability Limits do you desire:*

$100,000 CSL$300,000 CSL$500,000 CSL$1,000,000 CSLNot sure
Do you desire Uninsured motorist coverage*

YesNoNot sure
What Deductibles do you desire for Comprehensive and Collision*

$500$1,000$2,500$5,000I do not want Comp & Collision coverageNot sure
What else would you like to share to help us prepare the best policy for you?
If needing Commercial Auto, please include all driver information here including driving license numbers
Do you need other types of business insurance?*

Commercial General Liability (GL)Workers CompensationCommercial UmbrellaCommercial Real EstateTools & EquipmentNoneNot sure
How did you hear about us? *
Feel free to upload your current policy, declaration pages and ID Cards if available:

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Thank you for choosing us to assist you with your insurance needs. We are excited to provide you superior service and value.

Dodge Insurance Agency

DodgeAgency@outlook.com

702-827-6007
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