It is obvious that a vehicle owned by your business should be insured for both liability and replacement purposes. What is less obvious is that you may need special insurance (called "non-owned automobile coverage") if you use your personal vehicle on company business. This policy covers the business' liability for any damage which may result for such usage.

General Information:
 
1.  *First Name:  
2.  *Last Name:  
3.  *Phone:  
4.  *Email:  
5.  Address:  
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.
1) Description of the business:
2) What type of entity is your company?
3) Please indicate the state in which your business is located:
4) What is the date of incorporation?
MM   YY
/
5) Please indicate your total number of full-time employees:
(If Sole Proprietor enter 1)
6) Please indicate your total number of part-time employees:
(If none please enter 0)
7) Please indicate your total annual revenue:
8) Do you currently have business auto insurance? Yes No
9) If you are currently insured, please select your current insurance carrier:
10) If your provider is not listed above, please provide the company name here:
11) How many years have you had coverage with this company?
12) How many years have you had continuous coverage (With no lapse)?
13) If you do not have coverage please indicate when you would like a policy to go into effect:
14) Please indicate the number of automobiles you would like to insure:
Now, take a moment to tell us about the primary vehicles you wish to insure. Please list all other vehicles and their descriptions in the the other vehicles field.
Automobile Information
15) Year:
16) Make:
17) Model:
18) Type:
19) VIN:
20) If commercial, please enter GVW:
21) Number of Doors:
22) Fuel?
23) Cylinders?
24) Turbo/Supercharged? Yes No
25) 4-Wheel Drive? Yes No
26) Anti-Lock Brakes(ABS)? Yes No
27) Alarm Type?:
28) Number of Air Bags?:
29) Seat Belts?
30) Parking:
31) Annual Miles:
32) If new car, what is the MSRP:
33) Leased: Lease Own
Principle place the vehicle will be garaged:
34) Street:
35) City:
36) State:
37) Zip:
38) Best Time To Contact:
39) Additional Vehicles:
Please provide any additional vehicles you would like us to take into account.

Copyright 2003 [Your Company Name.LTD]. All rights reserved