Commercial Auto Form - Barakat & Associates Insurance Services

General Information

Current Insurance Company (not agency)

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #1

If vehicle is kept at an address other than that listed above, please indicate:



Vehicle #2

If vehicle is kept at an address other than that listed above, please indicate:



Vehicle #3

If vehicle is kept at an address other than that listed above, please indicate:



Vehicle #4

If vehicle is kept at an address other than that listed above, please indicate:



Driver Information (including all licensed drivers in your Business)

Driver #1



 M    F 

 M    S 

Driver #2



 M    F 

 M    S 

Driver #3



 M    F 

 M    S 

Driver #4



 M    F 

 M    S 

Driver #5



 M    F 

 M    S 

Liability

Additional Comments

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message