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Commercial Auto Policy Data Collection Form
Company Information
Company Name
*
Primary Point of Contact
*
Phone
*
E-mail
*
Website
Years in Business
Tax ID
Legal Entity
Individual
Corporation
LLC
Partnership
Business Address
Mailing Address
Current Insurance Carrier / Company
Current Insurance Policy Renewal or Expiration Date
+
Brief Description of Operations and Driving Exposure
Average Radius of Operations / Driving Distance Per Day
Estimated Number of Stops per day by you or your employees / drivers
Do your employees drive their own cars during work hours for business needs (errands / delivery / bank deposits / meeting with clients)
Yes
No
Commercial Auto Driver List
*If you have a list on a spreadsheet or in any other electronic form (WORD / PDF / EXCEL / Other) you can upload that form via this button.
Driver List
Driver 1
Last Name
First Name
DL Number
DL State
Date of Birth
+
Driver 2
Last Name
First Name
DL Number
DL State
Date of Birth
+
Driver 3
Last Name
First Name
DL Number
DL State
Date of Birth
+
Commercial Auto Vehicle List
*If you have a list on a spreadsheet or in any other electronic form (WORD / PDF / EXCEL / Other) you can upload that form via this button.
Vehicle List
Vehicle 1
Year
Make
Model
VIN
Original Cost New / Value (Estimate)
Additional Equipment / Value (If Any)
Vehicle 2
Year
Make
Model
VIN
Original Cost New / Value (Estimate)
Additional Equipment / Value (If Any)
Vehicle 3
Year
Make
Model
VIN
Original Cost New / Value (Estimate)
Additional Equipment / Value (If Any)
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