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COMMERCIAL VEHICLE #1: If more than 5 vehicles, list in remarks or call us at: 877-325-2242
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Radius of operation:
Gross Vehicle Weight:
Cost New: $
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #1
COVERAGES:
Limits of Liability:
$300,000 CSL
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #2:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Radius of operation:
Gross Vehicle Weight:
Cost New: $
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #2
COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #3:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Radius of operation:
Gross Vehicle Weight:
Cost New: $
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #3
COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #4:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Radius of operation:
Gross Vehicle Weight:
Cost New: $
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #4
COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #5:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Radius of operation:
Gross Vehicle Weight:
Cost New: $
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #5
COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists?
Yes
No
If you have more than 5 vehicles, list here. Also, if any of your drivers have significant driving record problems such as tickets and accidents, please tell us about it with any other remarks here:
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