Secured Page

COMMERCIAL VEHICLE INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on a Commercial Vehicle insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Medium to large size vehicles, 2 1/2 ton pick-up trucks or larger, flat beds, dump trucks, big rigs, local & long haul, owned by you or your company and used in the business. This form is designed for four vehicles and drivers. If you have more, submit another form.
If your vehicle doesn't fit into this category, select one of the options below:
Antique Auto if the vehicle is used mainly for exhibitions, club activities or parades.
Public Auto if the vehicle is a taxi, limousine, bus or shuttle bus.
Auto quote is for small to medium size vehicles, vans, pick-up trucks, four wheel drives and station wagons used for personal use not related to business and registered to you or a household family member.
Business Auto if the auto is a business use vehicle.
Garaging Information
What is your name?
Last
First
Middle
What is the garaging address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
Mailing Address
What is your mailing address? (if different from above)
Street
City
State
Zip
Driver Information
Driver 1
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 2
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 3
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 4
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
License Type
Vehicle Information
Vehicle 1
Year
Make
Model
I.D. Number
G.V.W.
Miles per year
Radius Driven (Average)
Ownership
Vehicle 2
Year
Make
Model
I.D. Number
G.V.W.
Miles per year
Radius Driven (Average)
Ownership
Vehicle 3
Year
Make
Model
I.D. Number
G.V.W.
Miles per year
Radius Driven (Average)
Ownership
Vehicle 4
Year
Make
Model
I.D. Number
G.V.W.
Miles per year
Radius Driven (Average)
Ownership
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Coverage Information
  Bodily Injury Property Damage
Personal liability
Uninsured motorist
Medical payment  
Deductible Information
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comp (theft)
Collision
Miscellaneous Information
Current Insurance Company
Expiration date
Current premium
How many stops a day average per vehicle?
Type of Product/ Cargo Hauled/ Carried
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
THE GLOVER AGENCY, LLC

145 E. BROAD STREET | EUFAULA, AL 36027
Phone 334-687-0358 or 888-882-2181
Fax 334-687-2365
 
 
This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.
Privacy Statement