Commercial Auto Questionnaire

Commercial Auto Questionnaire

Use this form to collect detailed client information for a commercial auto insurance policy application and underwriting review.
Applicant/Business Information
Legal Business Name
DBA
Primary Contact
Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Website
Coverage Request
Requested Effective Date

MonthDayYear
Date
Current Carrier
Current Policy Expiration

MonthDayYear
Date
Any lapse in past 3 years?
If yes, explain
Coverage Requested

Other
Vehicle Schedule
Vehicle Schedule
Driver Information
Driver Information
Driver Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Driver License Number
Issuing State
Hire Date

MonthDayYear
Date
Years of Driving Experience
Loss History
Any claims or losses in the past 5 years?
Loss runs attached?
Loss History
Please attach loss runs if available.
Operations Details
What do the vehicles transport?
Do the vehicles cross state lines?
Do the vehicles transport hazardous materials?
Are subcontractors used?
Are motor vehicle records checked before hire?
Is there a formal safety program?
Explain operations, routes, or special vehicle use
Filings/Regulatory Information
Filings Required

Other
DOT #
MC #
Additional Insured/Certificate Holder Requests
Use this section to list each additional insured or certificate holder separately, including any address or special requirement notes.
Additional Insured / Certificate Holder Entries
Notes
Should be Empty:

Commercial Auto Questionnaire

Applicant/Business Information

Coverage Request

Vehicle Schedule

Driver Information

Loss History

Operations Details

Filings/Regulatory Information

Additional Insured/Certificate Holder Requests