813-661-7200 800-606-7211 www.floridainsurancequotes.us www.floridaallianceinsurance.com

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.      This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days. 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): Select One $300,000 $350,000 $500,000 $600,000 $1,000,000 Uninsured Motorist - Bodily Injury (csl): Select One None $25,000 $50,000 $60,000 $100,000 $250,000 $350,000 $500,000 $1,000,000 Uninsured Motorist - Property Damage: Yes   No Medical: Select One None $500 $1,000 $2,000 $5,000 Hired Auto: Yes   No Non-Owned Auto: Yes   No Comprehensive Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000 Collision Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000 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. $ Select One Commercial Service Retail 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. $ Select One Commercial Service Retail 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. $ Select One Commercial Service Retail 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. $ Select One Commercial Service Retail 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. $ Select One Commercial Service Retail 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: Y N  Accident Prevention: Y N  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: Y N  Accident Prevention: Y N  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: Y N  Accident Prevention: Y N  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: Y N  Accident Prevention: Y N  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. This Commercial Automobile Quote Form Copyright © 2001 - by ENHANCED Web Services

Copyright © Florida Alliance - All Rights Reserved