Commercial Vehicle Application
Insurance Guide for Commercial Vehicle Coverage
With complete and accurate information we'll be able to provide you the expert price quotation you, like hundreds of other the Western States contractors, should expect of us.
1. This Auto insurace will be used for?
Commercial
Personal
2. General Information
Contractor License Number:
Insured/Contact
*
Company Name
*
Phone
*
Fax
E-mail Address
*
Policy Term Requested
Address
MAILING
Street Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
PREMISE
Street Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
3. Describe business operations
4. Years in business?
1
2
3
4
5
More than 5
5. Business Auto Schedule
Veh
No.
Year
Trade name
model and body
Serial Number
Gross
vehicle
weight
Stated
Amount
Radius
1
50
100
150
other
2
50
100
150
other
3
50
100
150
other
4
50
100
150
other
5
50
100
150
other
Veh
No.
Principal
Operator
Marital
Status
Date of
Birth
License
Number
State
Number
Violations
Number
Accidents
# of major
violations
1
Select
Married
Single
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
2
Select
Married
Single
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
3
Select
Married
Single
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
4
Select
Married
Single
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
5
Select
Married
Single
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
0
1
2
3
4
5
>5
6. Nature of business
Years in business
Prior Carrier Information / Name & Policy Number
7
.
Liability
Uninsured Motorist
Med Pay
Physical Damage
Select
15/30/10
50/100/50
100/300/50
250/500/100
300 CSL
500 CSL
600 CSL
750 CSL
1000 CSL
Select
15/30
25/50
30/60
50/100
100/300
Select
$1,000
$2,000
$5,000
Select
$250/$250
$500/$500
$1000/$1000
$2500/$2500
UMPD: Yes
No
Hired Auto: Yes
No
Non-owned Auto: Yes
No
8. Comments
Enter Text Above:
*
©2005 Commercial Specialists Insurance Services. All rights reserved.
License # 0D80851