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PUBLIC AUTO INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on a Public Auto 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.
Taxi, limousine and buses are the most common public form of transportation. Shuttle buses used in the course of a business are also acceptable under this program. 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.
Commercial Vehicle if the vehicle is a large size vehicle (2 1/2 ton or more) and used regularly in a business.
Business Auto if the auto is a business use vehicle.
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.
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
Type
Make
Model
I.D. number
G.V.W.
Miles per year
Radius driven (Average)
Number of stops per day
Maximum number of passengers
Number of seats
Stops at Airports
Ownership
Vehicle 2
Year
Type
Make
Model
I.D. number
G.V.W.
Miles per year
Radius driven (Average)
Number of stops per day
Maximum number of passengers
Number of seats
Stops at Airports
Ownership
Vehicle 3
Year
Type
Make
Model
I.D. number
G.V.W.
Miles per year
Radius driven (Average)
Number of stops per day
Maximum number of passengers
Number of seats
Stops at Airports
Ownership
Vehicle 4
Year
Type
Make
Model
I.D. number
G.V.W.
Miles per year
Radius driven (Average)
Number of stops per day
Maximum number of passengers
Number of seats
Stops at Airports
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
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:
     
 
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