3405 W Sterns Rd, Lambertville, MI 48144 (734) 568-6120

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COMMERCIAL AUTO QUOTE FORM


          Applicants Information

Name   Phone #  
Address   E-Mail  
    Fax #  
    Cell Phone #  

DBA 
Corporation Type (if any) 
Type of Business  
Any Special License / Training  Years in Business / Experience 
Current Carrier  Expiration Date 
Any Losses or Claims 

Describe Use of each Vehicle 
Radius of Operation States Driven
Is Owner Operated for Hire OR are they contracted to one company
If Contracted, Name of Company
Liability Limits UIM Limits Comp/Coll

          Vehicle Description

Year, Make Model V.I.N. Value

          Driver Information

Name Sex Marital Stat. DOB License # Soc. Sec. #

          Cargo Coverage Information

Is Cargo Insurance Needed 
If YES, Describe in Detail and Percentage of each type of Cargo carried
Cargo in Truck Overnight Is Alarm on Trailer Trailer Locked at all Time
     

          Additional Comments
 
 

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