Commercial Auto - Universal Marketing and management

Submission Date

Contact Name

Business Name*

Detailed Description of Business Operations* Please be very specific.

Website URL

Phone

Email*

Address

City

State*

ZIP Code

Business Start Date

Type of Insurance needed

Provide EIN Number

Projected Annual Revenue

How many full time employees?

How many part time employees?

Projected Annual Payroll

Have you had any Business Insurance Claims in the last 5 years?

Years of experience

Do you have a Security or Camera system?

Type of Company

Business owners details (full name and DOB)

Do you currently have or plan to obtain within the next 60 days a DOT number?

Enter DOT number for your business (optional)

How many years of prior commercial auto insurance does your business have?

Who is your current Insurance Carrier?

Current Annual Premium

Vehicle Information

Travel Distance per trip

Do you leave the State?

Vehicle Ownership Model

Number of Vehicles

Vehicle Information: VIN/Make/Model/Year

Vin

Make

Model

Year

Drivers Information

How Many Drivers

Drivers Full Name, DOB, License Number

First Name

Last Name

Date of Birth

License Number

State

CDL

General Information

1. With the exception of any encumbrances, are any vehicles for which insurance is requested not solely owned by and registered to the applicant? *

2. Do over 50 % of the employees use their autos in the business?

3. Is there a vehicle maintenance program in operation?

4. Are any vehicles leased to others?

5. Any car modified / special equipment? (Include customized vans / pickups)

6. ARE ICC (Interstate Commerce Commission), PUC (Public Utility Commission) OR OTHER FILINGS REQUIRED? (If "YES", attach ACORD 194)

7. Do operations involve transporting hazardous material?

8. Any hold harmless agreements?

9. Any vehicles used by family members? if so, identify.

10. Does the applicant obtain mvr(motor Vehicle Record) verification?

11. Does the applicant have a specific driver recruiting method?

12. Are any drivers not covers by workers compensation?

13. Any vehicles but not scheduled on this application?

14. Any drivers with convictions for moving traffic violations?

15. Has agent inspected vehicles?

16. Are all vehicles to be included in this policy of a fleet?

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