Commercial Auto Quote Information Form

Business Name (Include LLC, Inc, or DBA) or leave blank if using your name only

FEIN or EIN (Tax ID number) IF KNOWN. Otherwise, leave blank.

Name of the President, CEO, or Principal of the company

First NameMiddle NameLast NameSuffix

Will the President, CEO, or Principal of the company also be a driver on the policy?

President, CEO, or Principal of the company's information (Required by some insurance carriers)

President, CEO, or Principal of the company's HOME ADDRESS (Required by some insurance carriers)

Street Address

Street Address Line 2

CityState

Zip Code

Business Address (premises address, i.e., where vehicles are parked when not in use)

Street Address

Street Address Line 2

CityState

Zip Code

Is the business address also the mailing address?

Mailing Address (if different from the premises address)

Street Address

Street Address Line 2

CityState

Zip Code

Business Phone

Cell Phone (if different)

E-mail

Leave blank if no email address or email is not known.

How would you prefer that we contact you with your quote?

Driver Information

Vehicle Information - Current Value is required if you want comprehensive and collision.

What color(s) are your vehicles?

For multiple vehicles, please list each one with year, make, and color.

If any vehicle is financed or leased, then please provide the year/make of the vehicle and the name of the financing/leasing company below

Are all of the above vehicles owned or leased by the business name, or individual if no business name exists?

If there is a discount available for setting up automatic monthly payments from your checking account, are you interested in this? Please note that the down payment can still be made by credit card.

If there is a discount available for installing a telematics device in your vehicle(s), are you interested in this? ***THE POTENTIAL DISCOUNT IF YOU QUALIFY FOR PROGRESSIVE INSURANCE IS 15%.***

*** Do not answer Yes unless you are able and willing to install the necessary tracking device to your vehicle's OBD2 connector. ***

Estimate of annual mileage in the upcoming year

Estimated radius of operations *** Please select the radius where MOST of your trips will occur. The standard radius is 50 miles, but you are typically covered for occasional trips outside of this area. ***

Are vehicles used for business only, or is there also personal use? (If 'work & personal', indicate which vehicles are 'work only' and which ones are 'work & personal' in Additional Notes.)

Vehicle Equipment

Primary Vehicle Use

If carrying passengers, are at least 51% of customers' trips arranged the day before? Answering 'No' may result in higher insurance premiums, so please be sure on this one.

If you have a van or minibus, does it have perimeter seating?

List any NEMT companies, such as Modivcare, EpicMD, etc., that you will be working with:

If NEMT, will the vehicle have any of the following (if multiple vehicles, please specify NEMT features in the Additional Notes box below)?

If NEMT, will you be doing any work with nursing homes?

Will you do work with a ridesharing company such as Uber or Lyft?

Please select the types of transportation services you will offer:

What percentage of your trips will involve going to the airport?

Enter 0 if there will be no airport pick-ups. ***PLEASE NOTE THAT 80% OR MORE AIRPORT TRIPS MAY RESULT IN HIGHER PREMIUMS DUE TO CLASSIFICATION AS AN AIRPORT TAXI. ***

If carrying people for hire, at which airports (if any) will you pick up passengers?

Enter NONE if only doing drop-offs at the airport.

List any cities, counties, airports, or other entities that will require you to get a permit and/or provide a certificate of insurance:

How long has the business been open?

Enter NEW if starting a new company.

Have you had any COMMERCIAL AUTO INSURANCE in the last 3 years UNDER THE ABOVE BUSINESS NAME? (DOES NOT COUNT IF THE BUSINESS NAMES DO NOT MATCH)

Current/prior COMMERCIAL AUTO INSURANCE CARRIER

Enter UNK if not known.

Current/prior COMMERCIAL AUTO POLICY expiration date

MonthDayYear

How many years have you carried commercial auto insurance?

***Loss run reports may be needed for quotes. ***

Almost all insurance companies will require that we submit a copy of your claims record from all insurance carriers you've had during the last 3 years. This claims record is called a Loss Run Report and can only be sent to you or the agent who wrote your commercial auto policy. Please contact your current and prior insurance carriers to request your loss run reports and then email them to info@bigins.net.

Desired limits of liability

Do you have a DOT number, are you applying for a DOT number, or will you need to get one? (It is NOT typical to need a DOT number.)

Do you agree to opt in to receive text messages from Bullington Insurance Group, LLC?

Most insurance companies use information from you and other sources, such as your driving, claims and credit histories, to calculate an accurate price for your insurance. Please note that any checks of financial responsibility information will NOT impact or show up on your credit profile.

If you would like to see the privacy policies for your information, please email us at info@bigins.net so we can provide copies to you.

Additional Notes

Signature of applicant or Bullington Insurance Group, LLC representative who completed this form.