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Copyright 2000 [Thompson-Gusic Insurance Group,Inc. 
ALL RIGHTS RESERVED

Commercial Auto
Quote Form

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      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application. 


   -  Allow up to 2 weeks for a quotation, possibly more in Spring season.  We'll do our best to accommodate your due date.

GENERAL INFORMATION

Business Name (How Registered?):


Should match name of how vehicle(s) are registered. If veh's are registered differently, please address in comments (bottom).

 Phone: This # isCell Biz Home

Address:

 Contact:

City:

State:  Zip:  Email:

Brief Business Description:

 County:

Entity:

 Sole Prop.  Partnership  S-Corp  C-Corp  LLC  Quote Need By Date:

Federal ID#:

 Website:

POLICY INFORMATION

 Current Carrier: ORNo Current Carrier     Expiration Date:   Current Premium:

UNDERWRITING INFORMATION

 Any vehicles used by family members not associated with the business? N  Any drivers NOT covered by workers compensation? N
 Any vehicles customized, altered or have special equipment (ie Chair Lifts)? N  Are State PUC, Federal, or any other filings required?Y  N
 Do you provide transportation for your customers as part of your operations?Y  N  Do you have a DOT #?Y  N
 Do you provide transportation for people or property not associated with your operations?Y  N  Are any vehicles NOT titled in the above Business Name?Y  N
 Will all vehicles titled in your above company name scheduled for this quote?Y  N  
 Vehicles are primarily garaged overnight at this Address, City, State, Zip:
 COMMENT HERE IF DETAILS NEEDED FOR ABOVE ANSWERS

LOSS INFORMATION  -  Past 4 Years

Date of Loss

Description of Loss  -  Enter "NONE" in Description Line below if no losses.

Amount Paid

 The above information is correct to the best of my knowledge.  Check:   Initials:

 S T O P  - PLEASE  READ
 
If you have more than 5 vehicles, skip the following 3 BLUE sections and submit the Quote Form with only the above information completed.  Please email or fax the remaining information from your current policy. This will save us time.
 
   We need:
     1.  Vehicle Schedule Page(s)
     2.  Drivers Schedule
     3.  Limits of Insurance Page(s)
   EMAIL TO: insurance@thompsongusic.com   OR   FAX TO:  (877) 271-8898

 
If you do not have a large fleet, please continue completing all sections of the Quote Form and SUBMIT at bottom.

VEHICLE SCHEDULE / INFORMATION

Year

Make / Model / Type

V I N
(Vehicle Identification #)

Value
of
Vehicle

Livery
Max # of
Guests
Carried

Livery *
# Mths
Veh is in
Lay-Up

Radius of Use
(Miles)
"As the Crow Flies"

Compreh. Deductible

Collision
Deductible

 1.

 2.

 3.

 4.

 5.

     *Lay-Up=Months Veh is in Storage            

LIMITS OF INSURANCE

 Liability Limit: $2,000,000   $1,500,0000   $1,000,000    $500,000    $300,000    $100,000    Other:
 Uninsured Motorist Limit:   $1,000,000    $500,000    $300,000    $100,000.       Other:     
 Medical Payments:   $5,000     Other:
 Towing Reimbursement Coverage:  List Vehicle #'s (above) to Request Towing Coverage:
 Rental Reimbursement Coverage:  List Vehicle #'s (above) to Request Rental Reimbursement Coverage:
 Lease Gap Coverage:  List Vehicle #'s (above)  which are Leased:

DRIVER INFORMATION
Note:  Insurance Company can obtain various reports.  Any undisclosed accidents or
violations could result in an increase in premium or cancellation of coverage.

Name

Date of Birth

Drivers License #

State

List any Accidents or 
Violations w/in 3 Years

Is Driver
Married?
Driver have
a CDL?
Year CDL
Obtained

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No

ADDITIONAL COVERAGES / COMMENTS / INFORMATION

QUESTIONS / HELP

 Contact Office

Phone:

 (412) 271-8888   (9AM - 4:30PM EST)

Fax:

 (877) 271-8898

Email:

 insurance@thompsongusic.com