Commercial Auto Quote Information Form

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

First NameMiddle NameLast NameSuffix

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

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

Street Address

Street Address Line 2

CityState

Zip Code

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.

Driver Information*

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

What color 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?*

YesNo

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.

YesNo

If there is a discount available for installing a telematics device on your vehicle(s), are you interested in this? Please note that you will need an open OBD2 connector on your vehicle(s).

YesNo

Estimate of annual mileage in the upcoming year*

Estimated radius of operations *** Please select the radius where MOST of your trips will occur. The typical 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.)*

Work purposes onlyPrimarily work with occasional personal tripsA mix of work and personal use, i.e., vehicle is frequently used for personal trips

Vehicle Equipment*

Vehicle Use*

If carrying passengers, are a majority of customers' trips arranged at least 24 hours in advance?*

YesNo

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

YesNo

Are there any NEMT companies such as Modivcare, Alivi/EpicMD, etc. that you will be working with?

Enter UNK if NEMT and this information is not known.

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

Wheelchair RampWheelchair LiftAccommodates Stretchers

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

NoYes

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

No, I will be arranging private rides for hire only.Yes, I will be doing Uber Black and need commercial auto insurance for this.Yes, I will be doing a mix of regular ridesharing, e.g., Uber, Lyft, and private rides for hire.Yes, I will be doing only ridesharing, e.g., Uber, Lyft (requires personal auto policy only)

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?*

YesNo

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*

Are you required to have a DOT number or do you presently have one? (It is NOT typical to need a DOT number)*

NoYes

Additional Notes

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