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
Additional Vehicle Information:
Miles Cost Where Lienholder
Vehicle Driven New VIN# Garaged Yes/No
Florida Commercial Auto Insurance Coverage Information:
Liability Property Uninsured
Vehicle Combined Limits Damage Combined Limits Medical
2 SAME SAME SAME SAME
3 SAME SAME SAME SAME
Vehicle Deductible Deductible
Florida Driver Information:
Drivers Date of Drivers
Driver Name Birth Gender License #
Is each employee's driving record accident & violation free during the past 5 years?
1 If No, how many accidents? How many violations?
2 If No, how many accidents? How many violations?
3 If No, how many accidents? How many violations?
Was any employee's driver's license suspended during the past 5 years?
Recent Insurance Information:
Current Insurance Company:
Expiration Date: (mm/dd/yyyy)
Any losses past 3 years:
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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