Black Car / Limousine Insurance Quote Form
Insured Information:
Business Name
*
Federal EIN #
*
Business Type
*
Please Select
LLC
Corporation
Partnership
Sole Proprietorship
Non-Profit
Other
Year Business Started
*
DOT #
MC #
Are Filings Required
Please Select
Federal
State
Federal & State
None
Does the Business have a DBA?
Yes
No
DBA Name:
Business Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your mailing address the same as your business address?
*
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Owner Information:
Insurance companies required this information to provide a quote even if the owner is not a driver.
Owner First Name
*
Owner Last Name
Owner Cell Phone
Format: (000) 000-0000.
Owner Email
*
Business Owner License Information
*
Is the owner a company driver?
*
Yes
No
Business Driver(s) Information:
Please list ALL Company drivers.
Does the company have additional drivers?
*
Yes
No
All Drivers and License Information
*
Has ANY driver listed above had any violations or accidents within the last 3 years?
*
Yes
No
Please list the Driver name and briefly describe the ticket received or accident that occurred, for each driver involved.
Black Car / Limousine Vehicle INFORMATION:
Only submissions with complete vehicle information will be considered
Vehicle Information
*
Is the vehicle garaging address the same as the business address?
Yes
No
Garaging address (If different from business address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TRANSPORTATION OPERATIONS INFORMATION:
Business Operations Information:
*
Auto Liability and Physical Damage INSURANCE COVERAGE INFORMATION:
Primary Insurance Coverage Requested:
*
Auto Liability $1,000,000
Physical Damage
General Liability
Worker's Compensation
Auto Liability DEDUCTIBLE
*
$1,000
$2,500
$5,000
Additional Insurance Coverage Requested:
*
General Liablity Insurance Coverage Information:
Does your company require General Liability Insurance?
Yes
No
GENERAL LIABILITY INFORMATION*
*
Worker's Compensation:
Does your company require Workers Compensation Insurance?
Yes
No
Workers Compensation Information
*
Additional Interests
Please provide information for a lien or additional named insured or make payable to:
Are there Additional Interests that need to be added to the policy?
*
Yes
No
Additional Interest
*
Comments
Upload a copy of the Driver’s licenses and current MVRs, and/or loss run information. (If available)
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What Effective Date Would You Like for the Policy?:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Consent
The information you have provided is confidential and will be used by us to administer a response, document, or quote on your behalf. By submitting your data to us you agree to our storage and use of that data in this manner.
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Division
Lead Source
Lead Source Vendor
Pipeline
Deal Stage
Deal Type
Producer Email
Producer Name
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