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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
,
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NF
NS
ON
QB
SA
County
Garage Address 1 if Different from Mailing Address
Garage Address 2
Garage City, State Zip
,
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NF
NS
ON
QB
SA
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.