Commercial Auto Quote

MG Assurance Group LLC
2050 N Andrews Avenue, Unit 102 #1203
Pompano Beach, FL 33069
(754) 333-0691
gimi@mgassurancegroup.com
www.mgassurancegroup.com
Commercial Auto Quote
Customer Details:
Company Name
DOT Number
If no DOT#, enter 000000.
Company EIN Number
Owner

First NameLast Name
D.O.B.
MM/DD/YYYY
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Owner Driver's License # & State
Ex: W55509201 Florida or FL
Is Owner also a driver on the policy?
Does Owner have a CDL license?
Year the business was established?
"Year CDL License was Issued"
Contact Person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Garaging Address (leave blank if same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Loss Payees/Lease?
List Drivers

Driver #1
Driver's Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Year obtained
YYYY
License # & State
Ex: W55509201 Florida or FL
Would you like to add more drivers?
Driver #2
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Would you like to add more drivers?
Driver #3
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Year license obtained
YYYY
License # & State
Ex: W55509201 Florida or FL
Driver #4
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Vehicle Information
Vehicle # 1
Would you like to add another vehicle?
Vehicle # 2
Would you like to add another vehicle?
Vehicle # 3
Would you like to add another vehicle?
Vehicle # 4
Trailer Information
Trailer # 1
Would you like to add another trailer?
Trailer # 2
Would you like to add another trailer?
Trailer # 3
Would you like to add another trailer?
Trailer # 4
Does owner or driver have any tickets or accidents in the past 5 years? If so, please include the violations and dates.
Electronic Log Device (ELD)? If yes, please list company.
Description of Operations
Business Type
Does your business require Federal filings with FMCSA, if so please enter your MC Number?
If you have an MC number / Operating Authority with FMCSA, you will be required to have Federal filings. If not need enter No or n/a
Radius of Operations
If tow truck, do you do repos?
Do you cross state lines when operating your business?
Do you haul hazardous material?
Do you rent/lease your vehicles to others?
Types of commodities hauled: (please select at least 4 commodities)

Other
If 'other' selected, please list:
Type of Insurance Requested
Do you currently have a commercial auto policy?
Select the coverages needed
Auto Liability Limit (Choose the required coverage option).

Other
General Liability Limit (Choose the required coverage option).
Motor Truck Cargo (Choose the required coverage option).
Desired Deductible?
Do you currently have a personal auto policy? (10-20% Discount may apply)
How did you hear about us?
Should be Empty:

Commercial Auto Quote

List Drivers

Vehicle Information

Trailer Information

Description of Operations

Type of Insurance Requested