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Copyright 2000 [Thompson-Gusic Insurance Group,Inc. 
ALL RIGHTS RESERVED

Commercial Auto
Quote Form

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   -  Allow up to 1 week for a quotation

GENERAL INFORMATION

Business Name (How Titled?):


Must be name of how vehicle titled. If veh's are titled differently,
please address in comments (bottom).

 Phone:

Address:

 Contact:

City:

State:  Zip:  Email:

Business Description:

 County:

Entity:

 Sole Proprietor   Partnership    Corporation (or type of)   Quote Need By Date:

Federal ID#:

 

POLICY INFORMATION

 Current Carrier:   Expiration Date:   Current Premium:
  (Not Agency) State "NONE" if no current coverage.

UNDERWRITING INFORMATION

 1. Any vehicles used by family members?       N  4. Any drivers NOT covered by workers compensation?         N
 2. Are PUC, ICC or any other filings required? Y  N  5. Any vehicles customized, altered or have special equipment?Y N
 3. Any drivers under the age of 25?  Y  N  6. Are any vehicles NOT titled in the above Business Name?  Y  N
 PLEASE EXPLAIN "Y" (Yes) answers above:

LOSS INFORMATION  -  Past 3 Years

Date of Loss

Description of Loss  -  Enter "NONE" in Description Line below if no losses.

Amount Paid


 
The above information is correct to the best of my knowledge.  Check:   Initials:
  

 S T O P  &  READ

 
For a large fleet of vehicles, you may skip the following 3 BLUE sections and submit the Quote Form with 
 only the above information completed.  Please fax the remaining information from your current policy.   
   We need:
     1.  Vehicle Schedule Page
     2.  Drivers Schedule
     3.  Limits of Ins. Page
  
FAX TO:  (877) 271-8898

If you do not have a large fleet, please continue completing all sections of the Quote Form and submit.
SUBMIT button at bottom of FORM.

VEHICLE SCHEDULE / INFORMATION

Year

Make / Model / Type

V I N
(Vehicle Identification #)

Value
of
Vehicle

Livery
Max # of
Guests
Carried

Livery *
# Mths
Veh is in
Lay-Up

Radius of Use
(Miles)
"As the Crow Flies"

Compreh. Deductible

Collision
Deductible

 1.

 2.

 3.

 4.

 5.

   *Lay-Up = Months the Veh. is in Storage              

LIMITS OF INSURANCE

 Liability Limit:   $1,000,000      $500,000      $300,000      $100,000      Other:
 Uninsured Motorist Limit:   $1,000,000    $500,000    $300,000    $100,000.       Other:     
 Medical Payments:   $5,000     Other:
 Towing Reimbursement Coverage:    List Vehicle #'s (above) to Request Towing Coverage:
 Rental Reimbursement Coverage:    List Vehicle #'s (above) to Request Rental Reimbursement Coverage:
 Lease Gap Coverage:    List Vehicle #'s (above)  which are Leased:

DRIVER INFORMATION
Note:  Insurance Company can obtain various reports.  Any undisclosed accidents or
violations could result in an increase in premium or cancellation of coverage.

Name

Date of Birth

Drivers License #

State

List any Accidents or 
Violations w/in 3 Years

Is Driver
Married?
Driver have
a CDL?
Year CDL
Obtained

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

ADDITIONAL COVERAGES / COMMENTS / INFORMATION

QUESTIONS / HELP

 Contact Office

Phone:

 (412) 271-8888   (9AM - 4:30PM EST)

Fax:

 (877) 271-8898

Email:

 insurance@thompsongusic.com