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Business Auto Insurance Request
Business Auto Insurance Request Form
COMPANY INFORMATION
YOUR NAME: 
  ADDRESS: 
     CITY: 
    STATE:  ZIP: 
 EFFECTIVE DATE: 
EXPIRATION DATE: 
DRIVER INFORMATION
LIST ALL DRIVERS, INCLUDING GAMILY MEMBERS THAT WILL DRIVE COMPANY
VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS.
DRIVER # NAME D.O.B. YEAR LIC DRIVERS LICENSE NUMBER/
SOCIAL SECURITY NUMBER
USE VEH # % USE
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES IN REMARKS.

1. With the exception of encumbrances, are any vehicles
not solely owned by and registered to the applicant?

2. Do over 50% of the employees use their autos in the
business?

3. Is there a vehicle maintenance program in operation?

4. Are any vehicles leased to others?

5. Are any vehicles customized, altered or have special
equipment?

6. Are ICC, PUC or other filings required?

7. Do operations involve transporting hazarfous material?

8. Any hold harmless agreements?

9. Any vehicles used by family members? If so, identify in
remarks.

10. Does the applicant obtain MVR verifications?

11. Does the applicant have a specific driver recruiting
method?

12. Are any drivers not covered by workers compensation?

13. Any vehicles owned but not scheduled on this application?

14. Any drivers with moving traffic violations?


DESCRIPTION OF GARAGE/STORAGE LOCATIONS:


ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
         NAME: 
      ADDRESS: 
         CITY: 
        STATE:  ZIP: 

  REFERENCE #: 
             CERTIFICATE REQUIRED

 INTEREST:
Additional Insured
Loss Payee
Mortgagee
Lienholder
Employee As Lessor


Interest In Item Number
 LOCATION: 
  VEHICLE: 
 BUILDING: 
     BOAT: 
 SCHEDULED ITEM NUMBER: 

REMARKS
VEHICLE DESCRIPTION
      YEAR: 
      MAKE: 
     MODEL: 
 BODY TYPE: 
    V.I.N.: 
  COST NEW: 
   GVW/GCW: 
    RADIUS: 
 LOCATION WHERE GARAGED:
   CITY: 
  STATE:    ZIP: 

 DRIVE TO WORK/SCHOOL:
  Under 15 Miles
  15 Miles Or Over

 USE:
  Pleasure
  Farm
  Comm'l
  Retail
  Service

 DEDUCTIBLES:
 Comp. Deductible: 
 Coll. Deductible: 

Your Email Address:
  

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