Gessel & Associates Insurance Agency LLC - Commercial Vehicle Survey Quote Form

Agent/Account Manager:*

Quote Needed By:*

Current Carrier:*

Renewal Date:*

Current Premium:*

Describe Business Activity:*

APPLICANT

Name Insured:*

Doing Business As (DBA):*

(*Optional, and typically only used when the legal entity is a sole proprietor. Example- John Smith DBA Smith Construction)

Business Entity:*

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact Person:*

Business Phone:*

Cell Phone:*

Email:*

example@example.com

FEIN or SS#:*

Website:

Date Business Started:*

If new, provide details of Business Experience:

Any bankruptcies, tax or credit liens against the applicant in the past 5 years:*

YesNo

Verbal Disclosure:

Several carriers require the OWNER'S SS# for accurate rating. In connection with this application for insurance, we may review your credit report to obtain and use an insurance loss evaluation score which is based on credit related characteristics, we will use a third party in connection with the development of your insurance loss evaluation score. Entry of the SS# on this survey confirms the owner's acceptance to proceed in cases where the info is needed.

MVR Info For ALL Drivers:

Drivers:*

VEHICLE LIST:

Vehicles*

POLICY LEVEL COVERAGES:

Liability Limit (Select One):

Combined Single Limit (CSL) each AccountPer Person / Aggregate Per Accident

Enter text amount:*

Bodily Injury (Each Person):*

Bodily Injury (Each Accident Aggregate):*

Property Damage (Each Accident):*

Medical Payments:*

Hired Auto Lia – Est. Cost of Hire:

Non-Owned Auto Coverage:

Does the current policy provide Loss of Use on any vehicles?*

YesNo

IF yes, provide limit*

Do you need Cargo Coverage (Transportation Coverage may be a good alternative which can be written in package)*

YesNo

This survey does NOT contemplate Trucking risks.

LOSS HISTORY STATEMENT -

I, *, have owned and operated * for the past * years. To the best of my knowledge the CLAIMS HISTORY for my company is as follows:

Check if no known losses

IF any known losses, please list below: *

	Name	Description/Type of Loss	Approx. Amount Paid
1
2
3
4

I attest that, to the best of my knowledge, the information above is correct.

I understand that premiums quoted for my business will be based on the claims history information. I have provided above and that premiums may change based on a “verified loss run” from my current insurance carrier(s).

Applicant Signature*

Date*