APPLICATION

Commercial auto application

For contractors, service businesses, delivery and any business that puts vehicles on the road. For tractors, semi trailers and for-hire trucking, use the trucking application instead.

Business information

Legal business name

DBA, if different

Entity type

Years in business

Federal EIN Leave blank for a sole proprietor

Owner Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Contact name

Phone

Business address

City

State

ZIP code

Operations

What does the business do? Plumbing contractor, landscaping, food delivery, dealership

Number of employees

Annual revenue

Need hired and non-owned auto coverage? Employees driving their own vehicles for work, or rented vehicles

Liability limit required by contracts, if any $1,000,000 combined single limit is common

Certificate holders Who needs a certificate of insurance

Vehicles

Vehicle 1

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Vehicle 2

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Vehicle 3

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Vehicle 4

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Vehicle 5

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Vehicle 6

VIN

Year, make and model

Body type

Gross vehicle weight (lbs)

Stated value

Ownership

Lienholder or lessor

Operating radius

Coverage wanted

Drivers

Driver 1

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Driver 2

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Driver 3

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Driver 4

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Driver 5

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Driver 6

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Driver's license number

License state

Years of commercial driving experience

Tickets or accidents in the last 3 years Date and type, or "none"

Prior insurance

Current or most recent carrier

Current annual premium

Policy expiration date

Claims in the last 3 years Date, type and amount, or "none"

When do you need coverage to start?

Loss runs (optional) PDF under 4 MB. Carriers ask for 3 years.

Anything else

Notes for the agent