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*
E-mail *
example@example.com
Owner Driver's License # & State*
Ex: W55509201 Florida or FL
Is Owner also a driver on the policy?*

YesNo
Does Owner have a CDL license? *

YesNo
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? *

YesNo
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?

YesNo
Year obtained
YYYY
License # & State
Ex: W55509201 Florida or FL
Would you like to add more drivers?

YesNo
Driver #2
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?

YesNo
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Would you like to add more drivers?

YesNo
Driver #3
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?

YesNo
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?

YesNo
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Vehicle Information
Vehicle # 1
Would you like to add another vehicle?

YesNo
Vehicle # 2
Would you like to add another vehicle?

YesNo
Vehicle # 3
Would you like to add another vehicle?

YesNo
Vehicle # 4
Trailer Information
Trailer # 1
Would you like to add another trailer?

YesNo
Trailer # 2
Would you like to add another trailer?

YesNo
Trailer # 3
Would you like to add another trailer?

YesNo
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?

YesNo
Do you cross state lines when operating your business?*

YesNo
Do you haul hazardous material? *

YesNo
Do you rent/lease your vehicles to others? *

YesNo
Types of commodities hauled: (please select at least 4 commodities)*

General FreightHousehold Goods (moving/installing furniture)Metal: sheets, coils, rollsMotor VehiclesLogs, poles, beams, lumberBuilding materialsMobile HomesMachinery, Large objectsFresh ProduceLiquids/ gasesIntermodal Cont.PassengersOilfield EquipmentLivestockGrain, feed, HayCoalMeatGarbageUS MailDept. Store ProductsCommodities dry bulkRefrigerated foodBeveragesPaper/ Plastic ProductsAgricultural/ Farm suppliesConstructionOther
If 'other' selected, please list:
Type of Insurance Requested
Do you currently have a commercial auto policy?*

YesNo
Select the coverages needed *

Auto LiabilityGeneral LiabilityMotor Truck CargoPhysical Damage (Comp & Collission)Roadside AssistanceWorkers Compensation
Auto Liability Limit (Choose the required coverage option).*

$100,000$300,000$500,000$750,000$1,000,000Other
General Liability Limit (Choose the required coverage option).*

$1,000,000/ $1,000,000$1,000,000/ $2,000,000None
Motor Truck Cargo (Choose the required coverage option).*

$100,000$150,000$200,000$250,000$250,000 or moreNone
Desired Deductible? *

$1,000$2,500$5,000
Do you currently have a personal auto policy? (10-20% Discount may apply)*

YesNo
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