Commercial Auto Insurance Quote Form

Commercial Auto
Quote Form

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      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application.

   - Allow up to 2 weeks for a quotation, possibly more in Spring season. We'll do our best to accommodate your due date.

GENERAL INFORMATION

Business Name (How Registered?):	Should match name of how vehicle(s) are registered. If veh's are registered differently, please address in comments (bottom).	Phone: This isCell Biz Home
Address:		Contact:
City:	State: Zip:	Email:
Brief Business Description:		County:
Entity:	Individual Partnership S-Corp C-Corp LLC	Quote Need By Date:
Federal ID#:		Website:

POLICY INFORMATION

Current Carrier: ORNo Current Carrier Expiration Date: Current Premium:

UNDERWRITING INFORMATION

Any vehicles used by family members not associated with the business?Y N	Any drivers NOT covered by workers compensation?Y N
Any vehicles customized, altered or have special equipment (ie Chair Lifts)?Y N	Are State PUC, Federal, or any other filings required?Y N
Do you provide transportation for your customers as part of your operations?Y N	Do you have a DOT #?Y N
Do you provide transportation for people or property not associated with your operations?Y N	Are any vehicles NOT titled in the above Business Name?Y N
Will all vehicles titled in your above company name scheduled for this quote?Y N	Any vehicles have wheelchair lifts?Y N

Vehicles are primarily garaged overnight at this Address, City, State, Zip:

COMMENT HERE IF DETAILS NEEDED FOR ABOVE ANSWERS

LOSS INFORMATION - Past 4 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 - PLEASE READ
If you have more than 5 vehicles, skip the following 3 BLUE sections and submit the Quote Form with only the above information completed. Please email or fax the remaining information from your current policy. This will save us time.

   We need:
     1. Vehicle Schedule Page(s)
     2. Drivers Schedule
     3. Limits of Insurance Page(s)
   EMAIL TO: insurance@thompsongusic.com   OR   FAX TO: (877) 271-8898

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

VEHICLE SCHEDULE / INFORMATION

Year	Make / Model / Type	V I N (Vehicle Identification #)	Value of Vehicle	Livery Max # of Guests Carried	Layup * # Mths Veh is in Storage	Radius of Use (Miles) "As the Crow Flies"	Compreh. Deductible	Collision Deductible
1.
2.
3.
4.
5.
				* Vehicle is not operated during this time.

LIMITS OF INSURANCE

Liability Limit:$2,000,000 $1,500,0000 $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