Public Auto Quick Quote - For 4 or less vehicles only

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Public Auto Quick Quote - For 4 or less vehicles only


Agency Information:

* = Required
Agency Name*

Contact Person*

Email*
Phone

Fax


Applicant Information:

Business Name*

Mailing Address 1*

Mailing Address 2

City, State Zip*
, County

Phone*


Garage Address 1 if Different from Mailing Address

Garage Address 2

Garage City, State Zip
, Garage County

Federal ID or SSN

Applicant is
Individual:   Partnership:   Corporation:   Other: 

Maximum Radius of Operations*

Description of Business*

Year Business Started*

Date Coverage Desired

U.S. DOT Number*

Do you have an MC#?  Yes:  No: 
MC#

Are State filings needed? Yes:  No: 
List State(s) and Auth# (if app)

Form E? Yes:  No: 
Form H? Yes:  No: 
Additional Filings

Any Airport Exposure? Yes:  No: 
If Yes, Percentage

List Airports Entered


Schedule of Drivers*

Name
Date of Birth
State & License #
3 Yr Acc & Viol History
Yrs Exp*
Date of Hire
*Experience Driving Similar Vehicles

Vehicle Schedule

Year
Trade Name
Type of Vehicle
Seating Capacity
Length of Limo
Current Value
Maximum Radius

Prior 3 Year Carrier Information

 
Liability Carrier
Phys Dam Carrier
Cargo Carrier
Last Yr
1 Yr Prior
2 Yr Prior

Loss History

 
# Losses
Loss Amount Paid
Loss Description
Driver Name
Last Yr
1 Yr Prior
2-Yr-Prior

Coverages

Bodily Injury Liability/Property Damage Liability
Uninsured Uninsured Motorist Liability
Medical Payments Personal Injury Protection
Specified Cause of Loss Comprehensive
Collision
Other

Limits of Liability

$CSL
$CSL  $CSL
$Each Person
$Deductible
$Deductible


Cities Entered:
1. 2. 3. 4. 5.
Routes Followed
1. 2. 3. 4. 5.

Prior Employer Info (New Ventures Only)

Driver
Employer
Dates of Employment
Type of Unit
-
-

Additional Remarks

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Interstate Insurance Management is a series of RSG Underwriting Managers, LLC. RSG Underwriting Managers is a Delaware Series limited
liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Insurance Services, LLC License # 0E50879
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