Public Auto Quick Quote - For 4 or less vehicles only

Agency Information:

Agency Name

Contact Person

Email
Phone

Fax


Applicant Information:

Name of Applicant

DBA

Proposed Effective Date

Name of Owner

Mailing Address 1

Mailing Address 2

City, State Zip
,
County

Garage Address 1 if Different from Mailing Address

Garage Address 2

Garage City, State Zip
,
Garage County

# Years in Business

D.O.T. Number

Federal Filings?

State Filings?
Yes:  No: 
If yes, list states requiring filings


Breakdown of Transportation Service Provided (Number Vehicles and Percent of Trips):

Airport Bus

Airport Limo

Airport Shuttles

Amateur Sport Team

Ambulance

Athl & Entertainers

Charter Bus

Church Bus

Courtesy Bus

Day Care

Employee Transp

Gambling/Casino

Hotel/Mot Courtesy

Inter City Bus

Kiddie Cab

Limousine

Luxury Sedan/Corp

Paratransit

Party Bus

Physically Impaired

Prisoner Transp

Railroad Worker

School Bus

Sightseeing Bus

Taxi

Trolley Bus

Urban Bus

Van Pools

Other

Explain


Percent Radius of Operation:

0-25 Miles

26-50 Miles

51-75 Miles

76-100 Miles

101-300 Miles

300+ Miles

List all states in which vehicles operate

For all states, list largest cities entered

For all states, list farthest city entered from garaging location

Has any insurance company cancelled or nonrenewed applicant's policy in the last three years?
Yes:   No: 
If yes, explain


Are all vehicles registered and owned by the named insured?
Yes:   No: 
Does the insured allow any vehicles not owned/titled to them to operate under their authority?
Yes:   No: 
Does applicant currently operate using owner/operators?
Yes:   No: 
Is there personal use of vehicles?
Yes:   No: 
If yes, explain

Are any trips arranged thru a transportation network company (ridesharing) such as uber, lyft, sidecar, etc?
Yes:   No: 
If yes, what percentage?

What percentage of trips are arranged at least 24 hours in advance?

Is alcohol available in your vehicle?
Yes:   No: 
If yes, is it provided by the insured?

Provide insured's website or mark N/A


Drivers and Vehicles to Quote:

It is important to advise the applicant(s) that quotes are based on information provided here. If any discrepancies exist, additional premium(s) can be imposed or cancellation may result.

Driver information:

Name
Date of Birth
License #
Yrs Exp
State
Date of Hire

Vehicle information:

Year
Make
Model
Vehicle ID #
Seating Capacity
Stated Value
Radius
Length of Stretch
Coachbuilder* (Y/N)
Lift wheelchair/ scooter or ramp (Y/N)
Stretcher (Y/N)
*Coachbuilder required for all limousines stretched over 120”.

Coverages and Limits:

Auto Liability
 
CSL $
 
Split Limts
 
BI   $Per Person
 
BI   $Per Accident
 
PD $Per Accident
 
Uninsured/Underinsured $
 
PIP $
 
Medical Payments $
 
Hired Auto Liability
 
Non-Ownership Liability
Physical Damage
 
Comprehensive
 
OR
 
Specified Perils
 
Collision
General Liability
 
General Aggregate $
 
Per Occurrence $
 
SQ/FT



Answer all questions to avoid delay in quoting. For quote only: signed company application required to bind.must have four (4) years currently valued, hard copy company loss runs and current mvrs for all.


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

Legal  |  Privacy

RT Specialty is a division of RSG Specialty, LLC, a Delaware limited liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Specialty Insurance Services, LLC (License # 0G97516).