Commercial Non-Emergency Medical Insurance Quotation Information Form
Fill the fields below accurately and we will return back to you in a short time
E-Mail
*
Email
Website Address
*
If none please list "none"
Business Owners Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Company Name
*
Company Name
FEIN Number
*
Company Name
Is the Business Mailing Address the Same as the Garaging?
*
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Garaging Address (where will the vehicles be kept?)
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is the maximum distance you travel one way?
*
0-50 miles
50 - 100 miles
100+ miles
Do you have dash cameras?
*
Yes Forward Facing Only
Yes Dual Facing
No
Liability Limit Requested:
*
Please Select
300,000 CSL
500,000CSL
1,000,000 CSL
Physical Damage Deductible Requested
*
Please Select
Decline Coverage
1,000
2,000
5,000
General Liability Limit Requested
*
Please Select
Decline Coverage
300,000/600,000
1,000,000/2,000,000
Any other coverages that you would like to include? (Please list If none, list none.)
*
Example: Uninsured Motorist Coverage, General Liability,Personal Injury Protection, Medical Payments, Cyber Liability, Workers Compensation
Have you ever had previous commercial insurance?
*
Yes
No
Please list the years which you had the previous commercial insurance.
Upload Loss Runs from the past 3 to 5 years:
Browse Files
Drag and drop files here
Choose a file
Loss runs, which detail your claims history, can be obtained from your previous agency or insurance carrier. All carriers require these reports in order to provide an accurate quote.
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Please give a brief but in depth description of the businesses operations.
*
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Please list all Vehicles
If you have more vehicles than you are able to list on this form please email requests@ipa-insure.com. (This page will only allow for 5 vehicles)
Year
*
Make
*
Model
*
Vin Number
*
Seating Capacity
*
Is this vehicle equipped for:
*
Wheelchairs
Stretchers
Wheelchair and Stretcher
None
Do you have another Vehicle you would like to add?
*
Yes
No
Year
*
Make
*
Model
*
Vin Number
*
Seating Capacity
*
Is this vehicle equipped for:
*
Wheelchairs
Stretchers
Wheelchair and Stretcher
None
Do you have another Vehicle you would like to add?
*
Yes
No
Year
*
Make
*
Model
*
Vin Number
*
Seating Capacity
*
Is this vehicle equipped for:
*
Wheelchairs
Stretchers
Wheelchair and Stretcher
None
Do you have another Vehicle you would like to add?
*
Yes
No
Year
*
Make
*
Model
*
Vin Number
*
Seating Capacity
*
Is this vehicle equipped for:
*
Wheelchairs
Stretchers
Wheelchair and Stretcher
None
Do you have another Vehicle you would like to add?
*
Yes
No
Year
*
Make
*
Model
*
Vin Number
*
Seating Capacity
*
Is this vehicle equipped for:
*
Wheelchairs
Stretchers
Wheelchair and Stretcher
None
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Please list all Drivers:
If you have more drivers than you are able to list on this form please email requests@ipa-insure.com. (This page will only allow for 6 drivers)
Are all drivers trained in Passenger Assistance, Safety and Sensitivity (PASS)?
*
Yes
No, but we are getting this training.
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years experience driving commercially
*
Drivers License Number and State
*
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By clicking "I agree" below: I hereby certify that the information provided in this form is true, accurate, and complete to the best of my knowledge. The information provided in this form is collected for general underwriting and informational purposes only. Coverage selections or requests indicated herein may not be reflected in the quotes you have received. The quotes and policy documents themselves are the sole and controlling source of the coverages, limits, deductibles, endorsements, exclusions, and terms being offered. Applicants are advised to carefully review all quotes and policy documents in their entirety to confirm the exact coverage being proposed prior to binding coverage.
*
I agree and understand
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