Business Name:    
Premises Address:
City:
Florida
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 
Federal Employer's ID #:
Description of Operations or SIC code:


Florida Vehicle Information:
(if more than 3 commercial vehicles please provide best time to contact)

Vehicle     Year              Make              Model             Body Type
     1         Select One Four Door Sedan Two Door Coupe Sports Car Luxury Sedan Sports Utility Wagon-Minivan Pickup Truck Other
     2         Select One Four Door Sedan Two Door Coupe Sports Car Luxury Sedan Sports Utility Wagon-Minivan Pickup Truck Other
     3         Select One Four Door Sedan Two Door Coupe Sports Car Luxury Sedan Sports Utility Wagon-Minivan Pickup Truck Other

Additional Vehicle Information:

                Miles          Cost                                          Where              Lienholder
Vehicle   Driven         New            VIN#                    Garaged              Yes/No
     1             Select No Yes
     2             Select No Yes
     3             Select No Yes

Florida Commercial Auto Insurance Coverage Information:

                      Liability                 Property                   Uninsured
Vehicle  Combined Limits          Damage               Combined Limits         Medical
     1        Select One $50,000 $100,000 $150,000 $300,000 $500,000 $1 million             Select One $25,000 $50,000 $100,000             Select One $50,000 $100,000 $150,000 $300,000 $500,000 $1 million          Select One $5,000 $10,000 $25,000 $50,000
     2             SAME                       SAME                       SAME                   SAME
     3             SAME                       SAME                       SAME                   SAME


                   Collision         Comprehensive
Vehicle    Deductible           Deductible
     1        Select One None $250 $500 $1000       Select One None $500 $1,000
     2        Select One None $250 $500 $1000       Select One None $500 $1,000
     3        Select One None $250 $500 $1000       Select One None $500 $1,000

Florida Driver Information:

                                  Drivers                          Date of                                              Drivers
Driver                       Name                               Birth                  Gender                 License #
     1                     Select One Female Male     
     2                     Select One Female Male     
     3                     Select One Female Male     

Is each employee's driving record accident & violation free during the past 5 years?
Driver
     1       Select One No Yes   If No, how many accidents?    How many violations? 
     2       Select One No Yes   If No, how many accidents?    How many violations? 
     3       Select One No Yes   If No, how many accidents?    How many violations? 

Was any employee's driver's license suspended during the past 5 years?
Driver
     1       Select One No Yes
     2       Select One No Yes
     3       Select One No Yes

Recent Insurance Information:

Current Insurance Company: 
Expiration Date: (mm/dd/yyyy)
Any losses past 3 years: Select One Yes NO
Description of losses, including amount paid on each accident:


Additional Information or Comments



Click on the "Submit Quote Request" button below to send your
Florida Commercial Auto Insurance quote request.**

**Information received from this Florida Commercial Auto Insurance quote request form
sent to "YOUR AGENCY NAME" will be for our use only and will not be sold, given
to, or distributed to any other parties. A quote will be based on the Florida commercial auto
insurance information provided and does not guarantee acceptance of the risk by us.
The precise coverage afforded is subject to meeting underwriting guidelines, and the terms,
conditions and exclusions of the policy as issued. By submitting this request you
acknowledge that this is neither an offer to insure nor a guarantee of insurance.
Completion of this form does not entitle your business to a Florida Commercial Auto
Insurance policy. We are licensed in Florida and will not provide commercial auto
insurance quotes for other states.

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Florida Commercial Auto Insurance Quote

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