Florida Alliance
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Florida Alliance



 
Commercial Automobile Insurance Quote

We would like to provide you with a free, no-obligation commercial automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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General Information
Name of Insured:
Address:
City:   State:   Zip:
Business Phone:   Fax Number:
Email Address:
Garaging Address 
(type "same" if same as above):
City:   State:   Zip:


Coverage Information
Liability Amount (csl):
Uninsured Motorist - Bodily Injury (csl):
Uninsured Motorist - Property Damage: Yes   No
Medical:
Hired Auto: Yes   No
Non-Owned Auto: Yes   No
Comprehensive Deductible: Yes   No       If "Yes",
Collision Deductible: Yes   No       If "Yes",


Vehicle Information
You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles
AUTO
#1
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius
(in miles, one way)
Vehicle Use
lbs.
$
Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
AUTO
#2
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius
(in miles, one way)
Vehicle Use
lbs.
$
Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
AUTO
#3
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius
(in miles, one way)
Vehicle Use
lbs.
$
Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
AUTO
#4
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius
(in miles, one way)
Vehicle Use
lbs.
$
Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
AUTO
#5
Year
Make
Model
VIN #
Gross Vehicle Weight
Cost New
Radius
(in miles, one way)
Vehicle Use
lbs.
$
Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:


Driver Information
(include all commercially licensed drivers in your employ)
Driver
#1
Driver's Name
Drivers License Information
DL#: State: Yr's Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married  Single
Drivers Ed: 
Accident Prevention: 


Driver
#2
Driver's Name
Drivers License Information
DL#: State: Yr's Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married  Single
Drivers Ed: 
Accident Prevention: 


Driver
#3
Driver's Name
Drivers License Information
DL#: State: Yr's Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married  Single
Drivers Ed: 
Accident Prevention: 


Driver
#4
Driver's Name
Drivers License Information
DL#: State: Yr's Licensed:
Job Title
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married  Single
Drivers Ed: 
Accident Prevention: 


Driver History
List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver
Date
Type of Conviction
Fines
Speed Over Limit
$
mph
$
mph
$
mph
$
mph


List ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  


List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Fines
Injuries
At Fault
$
$
Yes
Yes
$
$
Yes
Yes
$
$
Yes
Yes
$
$
Yes
Yes

 
Loss Information
How many losses have there been in the last 3 years?  
(If any, please explain below)


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, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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