Commercial Car Insurance Quotation Form

1
Company NameLegal entity name
2
When should your Commercial Auto Policy Start?* This field is required.Effective date of policy
Date
Month
Day
Year
3
Do you have a USDOT Number?* This field is required.
4
Business Type* This field is required.
5
Name* This field is required.Owner's Name
First Name
Last Name
6
Business Address* This field is required.Address where the vehicle will be parked
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Date of BirthOwners date of birth
Date
Month
Day
Year
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Email* This field is required.
example@example.com
10
Are any vehicles used to haul to or from oil & gas fields?* This field is required.
Yes
No
11
Vehicle Information* This field is required.Add as many vehicles as needed - Please scroll through all the questions for each vehicle
12
Lien Holder/Finance Company* This field is required.Is there a loan/lease on any of the vehicles?
13
Drivers* This field is required.Please list all drivers - Please scroll through all the questions for each driver
14
Are You Currently Insured* This field is required.
Yes
No
15
Current/Prior Carrier Information* This field is required.Please scroll through all the information required
16
Other Business Insurance* This field is required.Do you have any other Insurance on your business?
General Liability
Business Owner's Policy
None
17
Liability Limit Needed* This field is required.
Please Select
Please Select
$10k/$20k/$10k
$25k/$50k/$25k
$125k/$250k/$50k
$100k/$300k/$50k
$250k/$500k/$100k
$50k CSL
$100k CSL
$300k CSL
$500k CSL
$750k CSL
$1 million CSL
$1.5 million CSL
$2 million CSL
Other
18
Comprehensive Deductible* This field is required.Comprehensive coverage protects the customer's vehicle if it is damaged by something other than a collision with a vehicle or object (such as hail or a falling tree), or if their vehicle is stolen. Comprehensive also covers damages from a collision with an animal.
Please Select
Please Select
$100.00 Deductible
$250.00 Deductible
$500.00 Deductible
$1,000.00 Deductible
$2,500.00 Deductible
$5,000.00 Deductible
Exclude
19
Collision Deductible* This field is required.Collision coverage protects the customer’s vehicle if it is damaged in an accident. It pays to repair or replace the vehicle if it collides with another object, overturns, or rolls. Collision coverage must be purchased with Comprehensive or Fire & Theft with Combined Additional Coverages.
Please Select
Please Select
$100.00 Deductible
$250.00 Deductible
$500.00 Deductible
$1,000.00 Deductible
$2,500.00 Deductible
$5,000.00 Deductible
Exclude
20
Medical Payments* This field is required.Medical Payments coverage pays certain medical and funeral expenses for the customer and any passengers in their vehicle who are injured during an accident or auto-related injury. This coverage is only available on power units.
Please Select
Please Select
$500 per person
$1k per person
$2k per person
$5k per person
Exclude
21
Rental Reimbursement* This field is required.Rental Reimbursement provides coverage for rental car costs to temporarily replace the customer’s vehicle due to a covered loss. Please review the policy contract for complete coverage information. Rental Reimbursement may be purchased for any vehicle covered by Comprehensive or Fire & Theft and Collision coverage.
Please Select
Please Select
$30 per day/ $900 max
$40 per day/ $1200.00 max
$50 per day/ $1500.00 max
Exclude
22
Roadside Assistance* This field is required.Roadside Assistance coverage provides towing to the nearest qualified repair facility and covers a specified amount of the necessary labor at the place of breakdown when the customer’s vehicle is disabled due to any of the following: • Mechanical or electrical breakdown • Dead battery • Flat tire • Lockout • Insufficient supply of fuel, oil, water or other fluids • Entrapment in snow, mud, water or sand within 100 feet of the roadway Towing and Labor service provided by other than one of our authorized service representatives will be reimbursed at reasonable charges, as determined by us. For heavy vehicle types (not available in all states), towing and labor are subject to a deductible and coverage limits as detailed in the policy and declarations page.
Yes
No
23
Fire & Theft w/ Combined Additional Coverage* This field is required.The Fire & Theft with Combined Additional Coverage option is a limited form of Comprehensive and only specific perils will be covered. The damage or loss must be caused by fire, lightning or explosion, theft, windstorms or hail, earthquakes, flood or rising waters, vandalism, collision with an animal, or while being transported by a third party.
Please Select
Please Select
$100 deductible
$250 deductible
$500 deductible
$1k deductible
$2,500 deductible
$5,000 deductible
Exclude
24
Would you like to add Hired Auto Liability* This field is required.Hired Auto provides liability coverage for hired (rented, leased or borrowed) vehicles used for the customer's business.
Yes
No
25
Would you like to add Employer Non-Owned Auto Liability* This field is required.Employer Non-Owned Auto Liability provides liability coverage for employees' vehicles while they are used for the customer’s business.
Yes
No
26
Would you like to add Motor Truck Cargo* This field is required.Motor Trucking Cargo coverage pays when the customer is responsible for damage to or loss of the cargo he or she is transporting due to fire, collision or even hitting or running over the cargo being transported.
Yes
No
27
Would you like to add Non-Owned Trailer Physical Damage* This field is required.Non-Owned Trailer Physical Damage provides Collision and Comprehensive coverage for trailers that are not owned by the customer but are used in the course of his or her business. This coverage is intended for trailers that will be in the customer's possession for less than 30 days at a time. If a trailer is in the customer's possession 30 days or more, please go back to the vehicle page and add the trailer so that it is listed on the policy.
Yes
No
28
Would you like to add General Liability* This field is required.General Liability coverage protects the customer's business when the customer is legally liable for bodily injury/property damage caused by an accident arising out of the customer's business operations (not directly involving the insured vehicle). Accidents caused by the operation of the insured vehicle are covered under Commercial Auto Liability coverage.
Yes
No
29
Any other details to assist us make informed decision?
30
Terms and Conditions* This field is required.
31
SignatureBy signing I agree that the information provided in this application is correct and true to the best of my knowledge.
Clear
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