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COMMERCIAL AUTOMOBILE QUOTE
Applicant's Name:
Mailing Address:
City  State     Zip
Phone:      Fax: 		PROPOSED EFFECTIVE DATE:
From     To

Email:

 
 Applicant is:   Individual Corporation Partnership Joint Venture
                            Other (Specify)

 Years in Business:           Contact Name:
Garaged Address:
 Address: County:  
 
 City:  State:   Zip:
Physical Address:
 Physical Address same as Mailing Address
 
 Address:
 
 City:   State:   Zip:
 CURRENT INSURANCE INFORMATION
 
 Company Name (not agency):     Policy Expiration Date:
 Years insured:   Premium Amount: $    Term:      If Other:
 If less than 3 years, prior company:
 
 Prior Losses/Dates (last 3 years):

 
SCHEDULE OF AUTOS
Car
Year
Make
Model
Gross Weight
Value
Loss Payee
1
2
3
4
5
6


 COVERAGES
  Liability Limit     Deductibles    Cargo Limit

  Physical Damage    
  Personal Injury Protection
  Uninsured/Underinsured Motorist

 TRANSPORTING
 Whom do you haul for?

 Commodities Transported (Include % of Each):
Radius:    Major Cities:
 
States (Include % of Each):

 Filings Required:
  Texas DOT
  ICC
  Other:  

Driver
Name
Birthdate
Years Experience
Violations/Dates
1
 
2
 
3
 
4
 
5
 
6
 

 

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