Business Information
Business Name
Contact Name
Address
City
State
Zip
Day Phone
Night Phone
Best time to Call		AM PM
E-mail Address
FAX
Federal Employer's ID#
Description of Business or SIC Code

Current Auto Insurance Information
Company Name (not agency)
Policy Expiration Date
Term	6 months	1 year	other

Vehicle Information
If more than four vehicles click here.
(include all vehicles you or your business owns or leases)
Vehicle #1	Year	Make	Model	Body Type
Vehicle ID# (VIN)	Anti-Lock Brakes		Car Alarm	Airbags
	yes no		yes no	yes no

Vehicle #2	Year	Make	Model	Body Type
Vehicle ID# (VIN)	Anti-Lock Brakes		Car Alarm	Airbags
	yes no		yes no	yes no

Vehicle #3	Year	Make	Model	Body Type
Vehicle ID# (VIN)	Anti-Lock Brakes		Car Alarm	Airbags
	yes no		yes no	yes no

Vehicle #4	Year	Make	Model	Body Type
Vehicle ID# (VIN)	Anti-Lock Brakes		Car Alarm	Airbags
	yes no		yes no	yes no

Liability Limit For All Cars
Bodily Injury	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Property Damage	$25,000 $50,000 $100,000 $500,000
Uninsured Motorist	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000

Deductibles and Misc.
Car #	Comprehensive Deductible	Collision Deductible	Towing	Rental Reimbursement
1	0 $250 $500 $1000	0 $250 $500 $1000	yes	yes
2	0 $250 $500 $1000	0 $250 $500 $1000	yes	yes
3	0 $250 $500 $1000	0 $250 $500 $1000	yes	yes
4	0 $250 $500 $1000	0 $250 $500 $1000	yes	yes

Driver Information
(include all licensed drivers in your business)
Driver #1	Driver's Name	Driver's License Information
		DL# State
	Date of Birth	Sex
		M F

Driver #2	Driver's Name	Driver's License Information
		DL# State
	Date of Birth	Sex
		M F

Driver #3	Driver's Name	Driver's License Information
		DL# State
	Date of Birth	Sex
		M F

Driver #4	Driver's Name	Driver's License Information
		DL# State
	Date of Birth	Sex
		M F

Driver History
Please list ANY Accidents/Violations/Suspensions of Any driver in the past 5 years.
Driver	Date	Type of Violation

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.