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: *

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