Questions?
Ask the Agent! Use the form below
or give us a call.
Phone: (800) 750-8888
Fax: (866) 353-3083
Commercial Vehicle Quote Form One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL DATA:
Your Name:
Business Name:
Street Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail: (Required)
Phone:
Fax: (Optional)
Your Company Website:
Currently Insured?
(If yes, list carrier, and # of years continuous. If no, type
NONE)
Type of Business:
(Please be specific, and tell how vehicles are used.)
DRIVER INFORMATION #1 (if more than 2 drivers, list in
remark)
Name:
Birth Date:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or call us at: 800-750-8888
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.)
Length in Feet:
Gross Vehicle Weight:
Cost New $:
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #1
COVERAGES:
Limits of Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #2:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle Weight:
Cost New $:
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #2
COVERAGES:
Limits of Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
Thank you for filling out this form
COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
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HAD / Professional Insurance Associates, Inc | Mailing Address: P.O. Box 8480, Porter Ranch, CA 91327
1100 Industrial Road, Suite 3, San Carlos, CA 94070 | 6320 Canoga Avenue, Suite 1500, Woodland Hills, CA 91367
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