Commercial Auto Insurance Questionnaire

Commercial Auto Insurance Questionnaire

SD Insurance Agency | (619) 800-7515 | Info@sdinsagency.com
Business Information
Legal Business Name
DBA / Trade Name
Business Entity Type
Primary Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Owner / Primary Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Type of Business / Industry
Years in Business
Number of Employees
Annual Gross Revenue ($)
Vehicle Information
Total Number of Vehicles to Be Insured
Vehicle 1 - Year
Vehicle 1 - Make
Vehicle 1 - Model
Vehicle 1 - VIN Number
Vehicle 1 - Stated Value / Purchase Price ($)
Vehicle 1 - Primary Use
Vehicle 1 - Radius of Operations
Vehicle 1 - Is this vehicle owned, leased, or financed?
Vehicle 1 - Lienholder / Lessor Name and Address
Do you have additional vehicles?
Additional Vehicles - Please list Year, Make, Model, VIN, Value, and Use for each additional vehicle
Driver Information
Total Number of Drivers
Driver 1 - Full Name

First NameMiddle NameLast Name
Driver 1 - Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver 1 - Driver License Number
Driver 1 - State of License
Driver 1 - Years of Driving Experience
Driver 1 - Any accidents or violations in the past 3 years?
Driver 1 - If yes, describe each incident - date, type, at-fault or not
Do you have additional drivers?
Additional Drivers - Please list Name, DOB, License Number, State, Years Experience, and any incidents for each additional driver
Do employees drive company vehicles?
Do you have a written driver safety policy?
Do you run motor vehicle record checks on drivers?
Coverage Requirements
Liability Limit Requested
Do you need Physical Damage coverage?
Comprehensive Deductible Requested
Collision Deductible Requested
Do you need Uninsured/Underinsured Motorist coverage?
Do you need Medical Payments coverage?
Do you need Hired Auto coverage?
Do you need Non-Owned Auto coverage for employees using personal vehicles?
Do you haul any cargo or equipment?
If yes, describe cargo or equipment and estimated value ($)
Do you need Motor Truck Cargo coverage?
Do any vehicles have special equipment or modifications?
If yes, describe modifications and value ($)
Do you require any Additional Insureds or Certificate Holders?
If yes, provide name and address of each
Current Coverage & Loss History
Are you currently insured for commercial auto?
Current Insurance Carrier
Current Annual Premium ($)
Policy Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you had any auto insurance claims in the past 5 years?
If yes, describe each claim - date, vehicle, type of loss, amount paid
Has your coverage been cancelled or non-renewed in the past 3 years?
If yes, please explain
Additional Information
Do any vehicles operate out of state?
If yes, which states?
Do you transport passengers for hire?
Do you transport hazardous materials?
Do you have a DOT number?
DOT Number
Do you have a garage or parking facility for vehicles?
Where are vehicles stored overnight?
Additional notes or special requests
Preferred policy effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Commercial Auto Insurance Questionnaire

Business Information

Vehicle Information

Driver Information

Coverage Requirements

Current Coverage & Loss History

Additional Information