Commercial Auto Intake Form
Company Information
Owner Name
*
First Name
Last Name
Email
*
example@example.com
Company name and entity (LLC, Corporation, Sole proprietor, etc.)
*
Company Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
When do you need this policy to start?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FEIN
*
Current Commercial Auto Insurance Company (non auto)
*
If you don't currently have commercial auto insurance, what company are your personal autos insured with?
*
What are your current auto liability limits?
*
30,000/60,000
50,000/100,000
100,000/300,000
250,000/500,000
Driver Information
Will the owner be a driver on this policy?
*
Yes
No
If yes, what is his/her drivers license number? Please include state.
*
Next Driver
Next Driver
Next Driver
Next Driver
Next Driver
Next Driver
Vehicle Information
Vehicle 1
Additional Info for Vehicle 1
Is this vehicle for personal or professional use?
*
Business only
Personal only
Business and personal
If this vehicle has a hitch, what type is it?
*
Vehicle 2
Additional Info for Vehicle 2
Is this vehicle for personal or professional use?
Business only
Personal only
Business and personal
If this vehicle has a hitch, what type is it?
Vehicle 3
Additional Info for Vehicle 3
If this vehicle has a hitch, what type is it?
Is this vehicle for personal or professional use?
Business only
Personal only
Business and personal
Vehicle 4
Additional Info for Vehicle 4
Is this vehicle for personal or professional use?
Business only
Personal only
Business and personal
If this vehicle has a hitch, what type is it?
Vehicle 5
Additional Info for Vehicle 5
Is this vehicle for personal or professional use?
Business only
Personal only
Business and personal
If this vehicle has a hitch, what type is it?
Vehicle 6
Additional Info for Vehicle 6
Is this vehicle for personal or professional use?
Business only
Personal only
Business and personal
If this vehicle has a hitch, what type is it?
Coverages
What levels of liability do you wish to carry? You may need to look at any contracts you have?
*
100/300
250/500
500/500
1,000,000/1,000,000
Other
Do you want roadside assistance?
*
Yes
No
Do you want rental coverage?
*
Yes
No
Do you need to add coverage for your employee's vehicles because they use them to do their jobs, even if just to run to the bank?
*
Yes
No
Contractual Requirements
Are you required by any of your contracts to carry a waiver of subrogation?
*
Yes
No
Are you required by contract to have any additional insureds?
*
Yes
NO
Submit
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