You may use this convenient online quote request for up to 3 vehicles
and up to 3 drivers.  For larger accounts or if you prefer, please call 561.395.9858

Click here for a quote on your business Insurance!

Please provide the following information about your business, your drivers and your vehicles

Name   Position    Company 
Address Address (con't)
City   State     Zip Code  
E-mail

How should we contact you?   

Phone Ext: If applicable, best time to call   
FAX   Description of Operations 
Driver 1    Name    Date of Birth     mm/dd/yyyy

Marital StatusSingle  Married   |    Sex  M     F

Driver 2     Name    Date of Birth     mm/dd/yyyy
Marital StatusSingle   Married  |    Sex  M     F

Driver 3     Name    Date of Birth   mm/dd/yyyy

Marital StatusSingle   Married  |    Sex  M     F

Fleet Information

Vehicle 1  Year  Make    Model    Annual Miles 

Type Dump, Tractor, Panel, Van, etc.             Actual Cash Value 

Principle Operator Driver 1   2   3       Exact Use 

Existing Damage  Yes No     Where Garaged?    GVW   lbs.

 

Vehicle 2   Year  Make    Model    Annual Miles 

Type Dump, Tractor, Panel, Van, etc.             Actual Cash Value 

Principle Operator Driver 1   2   3       Exact Use 

Existing Damage  Yes  No     Where Garaged?    GVW   lbs.

 

Vehicle 3   Year  Make     Model    Annual Miles 

Type Dump, Tractor, Panel, Van, etc.             Actual Cash Value 

Principle Operator Driver 1   2   3      Exact Use   

Existing Damage  Yes No     Where Garaged?     GVW   lbs.

Select Coverages     (click on coverage for brief explanation)
Note:  It is possible that all coverages and/or all limits are not available through all of the companies we represent.  We will come as close to your request as possible and advise you of the actual coverages we quote.
Bodily Injury Liability  
Property Damage Liability
Medical Payments    
Uninsured and Underinsured Motorist    
Comprehensive  Deductible       If no coverage desired, leave "None"
Collision Deductible       If no coverage desired, leave "None"
Accidental Death & Dismemberment    
Towing & Rental  (if available on your vehicle)
Same Coverage All Vehicles? Yes  No
If you do not want the same coverage for all vehicles, please describe coverage desired:

General Information
1. All vehicles registered to applicant? Yes   No
5. Any drivers with physical or mental impairments? Yes   No
6. Any driver's license been suspended or revoked? Yes   No
7. Any insurance declined, cancelled or non-renewed past 3 years? Yes   No

Accidents or Tickets

Examples of description of accidents or convictions: Speeding  52/35  (52 mph in a 35 mph zone) OR Accident at fault with Careless Driving Ticket, OR, Accident not at fault - only the other driver ticketed
Date Driver First Name Describe Accident or Conviction
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
Prior or Current Insurance Company
Current Expiration/Cancellation Date   mm/dd/yyyy
Have you been cancelled? Yes No
Has your insurance lapsed? Yes No
Special Requests or Comments:


 

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