Commercial Vehicle Insurance Quote

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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
What is your telephone number?	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:


	COLEMAN/AUTO INSURANCE 945 PERRY HIGHWAY \| PITTSBURGH, PA 15237 Phone 800-931-2922 Fax 412-366-9364

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