Davis and Madden Insurance

Commercial Auto Insurance Quote

To receive a quote for Commerical Auto Insurance, please provide us with the following information. Your current policy should have most of the information needed. All information submitted through this form will remain confidential. Our office will contact you or you may contact us.

Business Name:
Contact:
Address 1:
Address 2:
City, State, Zip:

Email:
Phone:	(include area code)
Fax:	( include area code)
Insurance Status:	None Insured New Business
If yes, who is the current company?
Expiration Date: Years With Company:
Vehicle registered to:
Is the business incorporated?
Do you have a general liability policy?
Do you offer worker's compensation?
How many vehicles does the company own?

Driver's Information

Drivers Name	Drivers License#	Years Licensed	Tickets*	Accidents
1
2
3
4
5

*Number of tickets and Accidents you have had in the last 3 years.

Additional Driver's Information

Type of Drivers License	Driving Courses completed	Marital Status
1
2
3
4
5

Vehicle Info

When listing vehicles, assume that Driver 1 primarily drives Vehicle 1 and Driver 2 primarily drives Vehicle to etc.

Vehicle	Year (1996)	Make (Ford)	Model	Body Type:	GVW
1
2
3
4
5


Vehicle 1	Current value of vehicle:
Vehicle 2	Current value of vehicle:
Vehicle 3	Current value of vehicle:

Insurance Coverage

Vehicle Id#
(If available)

Vehicle	Vehicle Leased?	Comprehensive Deductible:	Collision Deductible:
1		Yes No
2		Yes No
3		Yes No

Liability Coverage

Liability Coverage:	Property Damage:	Uninsured Motorists	Auto Medical payments

Include Towing/Emergency Road Service in quote.

Include Rental Replacement in the quote.

Add additional comments or questions here.

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