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| AUTO & EQUIP
QUOTE INFORMATION |
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| Proposed
Effective Date: |
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| Name of Company: |
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| Auto
Liability limits desired: |
$300,000 CSL |
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$500,000 CSL |
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$1,000,000 CSL |
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| Uninsured Motorist: |
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$50,000 |
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$100,000 |
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Other |
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| Comp/Coll Deductible: |
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$500/$500 |
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$1,000/$1,000 |
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| Med Pay |
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$2,000 |
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$5,000 |
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Other |
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| Radius Of Operations: |
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Miles |
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| Are
you transporting hazardous materials? |
Yes |
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No |
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| Are
all vehicles registered to the business? |
Yes |
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No |
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| If
no, please explain and provide copies of registration: |
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| Do
owners / officers have personal auto insurance coverage? |
Yes |
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No |
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| If not, DOC required on: |
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| VEHICLE
INFORMATION (Cost includes any permanently attached rigs,
etc.): |
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| Year / Make Model |
VIN# |
Cost |
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| DRIVER
INFORMATION: |
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| Name |
DOB |
State |
License Number |
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| EQUIPMENT LIST: |
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| Description |
Value |
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| *
In order to apply for rate experience discounts, please list Auto Liability
insurance experience for the past four (4) years. |
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| CURRENT YEAR: |
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COMPANY: |
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LOSSES: |
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| 1st PRIOR YEAR: |
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COMPANY: |
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LOSSES: |
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| 2nd PRIOR YEAR: |
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COMPANY: |
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LOSSES: |
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| 3rd PRIOR YEAR: |
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COMPANY: |
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LOSSES: |
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