Commercial Auto Form - Barakat & Associates Insurance Services

Commercial Auto Quote Form

 
General Information
Name of Business*
Contact Name*
Street Address*
City*
 State: ZIP:
Phone*
( )
Email 
Fax
( )
Best time to call
AM PM
Current Insurance Company (not agency)
Company Name
Policy Exp. Date
Current Premium
Vehicle Information (include all cars you or your business owns or leases)
Vehicle #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
If vehicle is kept at an address other than that listed above, please indicate
Location City:  State:  Zip:
Full Coverage:  yes no
Seasonal Use:  yes no
- Used:  From to
Vehicle Used for:   Season Used: 
Vehicle Information (include all cars you or your business owns or leases)
Vehicle #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
If vehicle is kept at an address other than that listed above, please indicate
Location City:  State:  Zip:
Full Coverage:  yes no
Seasonal Use:  yes no
- Used:  From to
Vehicle Used for:   Season Used: 
Vehicle Information (include all cars you or your business owns or leases)
Vehicle #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
If vehicle is kept at an address other than that listed above, please indicate
Location City:  State:  Zip:
Full Coverage:  yes no
Seasonal Use:  yes no
- Used:  From to
Vehicle Used for:   Season Used: 
Vehicle Information (include all cars you or your business owns or leases)
Vehicle #4 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
If vehicle is kept at an address other than that listed above, please indicate
Location City:  State:  Zip:
Full Coverage:  yes no
Seasonal Use:  yes no
- Used:  From to
Vehicle Used for:   Season Used: 
Driver Information (including all licensed drivers in your Business)
Driver License Number:   State: 
 
Driver's Name Occupation Relation to you Date of birth
(Mo/Day/Yr)		 Male/Female
(M / F)		 Married/Single
(M/S)		 # of Yrs.
Licensed
Self
 M 
 F 
 M 
 S 
 M 
 F 
 M 
 S 
 M 
 F 
 M 
 S 
 M 
 F 
 M 
 S 
 M 
 F 
 M 
 S 
Liability
Class of Business:
 Retail  Wholesale  Retail or Wholesale
 Service  Truckers  Food Concessions
Limits Requested  $1,000,000
Describe any claims you had in the past 3 years
Additional Comments
Please give any additional comments about the coverage you desire
 
* = Required Field
Thank you for your time in submitting this Commercial Auto Insurance Quote Form.
One of our representatives will respond to your submission as soon as possible!