Commercial Auto

Please provide the following information:

Name
Title
Organization
Street address
Address (cont.)
City
State
Zip Code
Work Phone
Home Phone
Fax
E-mail

Commercial Auto Information

	Auto #1	Auto #2	Auto #3	Auto #4
Year
Make
Model
VIN #
Miles Per Year
Anti-Theft Device
Gross Weight
Cost New

How is vehicle used? (Personal, Service, Commercial or Retail)

Vehicle #1 Personal Service Commercial Retail #2 Personal Service Commercial Retail #3 Personal Service Commercial Retail #4 Personal Service Commercial Retail

Coverage Information

	Auto #1	Auto #2	Auto #3	Auto #4
Bodily Injury	20,000/40,000	20,000/40,000	20,000/40,000	20,000/40,000
Personal Injury Protection.	8,000	8,000	8,000	8,000
Opt. Bodily Injury	20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000
Property Damage	5,000 10,000 15,000 20,000 25,000 50,000 100,000	Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000	Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000	Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000
Medical Payments	None 5,000 10,000 15,000 20,000 25,000 50,000 100,000	None 5,000 10,000 15,000 20,000 25,000 50,000 100,000	None 5,000 10,000 15,000 20,000 25,000 50,000 100,000	None 5,000 10,000 15,000 20,000 25,000 50,000 100,000
Uninsured Motorists	20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000
Underinsured Motorists	20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000	Select 20,000/40,000 25,000/50,000 30,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/1,000,000
Comprehensive	No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible
Collision	No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible	Select No Coverage 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible
Limited Collision	No Coverage No Deductible	No Coverage No Deductible	No Coverage No Deductible	No Coverage No Deductible
Loss Of Use	No Coverage $15/day ($450 max) $30/day ($900 max)	Select No Coverage $15/day ($450 max) $30/day ($900 max)	Select No Coverage $15/day ($450 max) $30/day ($900 max)	Select No Coverage $15/day ($450 max) $30/day ($900 max)
Towing	No Coverage $25/disablement $50/disablement	Select No Coverage $25/disablement $50/disablement	Select No Coverage $25/disablement $50/disablement	Select No Coverage $25/disablement $50/disablement

Driver Information

Name	Date of Birth	License Number	State