Commercial Trucks & Autos

For California Businesses only

COMMERCIAL TRUCK vs. PERSONAL TRUCK (Why should I put my trucks on a Commercial Policy?)

After you've completed this form, click on the SUBMIT button to receive your free Commercial Truck Insurance quote. You'll be given an opportunity to specify U.S. Postal Service, e-mail or fax. Or call us at (760) 644-0351.

THE FOLLOWING ARE GUIDELINES FOR THIS PROGRAM: NO TOW, GRAVEL OR SAND TRUCKS NO LONG HAUL (OVER 300 MILES)

Applicant Information
Named Insured Legal Name
E-mail
Home Street Address
Home City
Home County
State
Home Zip Code
Contact Phone
FAX
Social Security Number:
Birthdate:

Business Information
Business Name
Business Street Address
Business City
Business County
State
Business Zip Code
Business Web-Site
Describe Type of Business
Legal Entity	-- select -- Individual Partnership Corporation
If Partnership or Corporation, is the above Applicant principal of the company?	Yes No
If NO, enter the Name for the Principal of the operation:
Principals Social Security Number:
Principals Birthdate:
Years in business
Any bankruptcies or tax liens in past 3 years?	Yes No
Years experience driving this type of vehicle:	0-2 years   3-5 years   6 or more years
Do you require any State or Federal Filings?	Yes No
Do you lease out vehicles to a 3rd party?	Yes No
Do you have a MC(Motor Carrier) Number?	Yes No
What is the MC(Motor Carrier) Number for the filing?

Rating Information
Requested Effective Date:
Are you currently insured?	Yes No
Have you been insured for the past 12 months with no lapse in coverage?	Yes No
Current Policy Number:
Current Insurance Carrier:
Current Policy Expiration Date:
Current Liability Limit:
How many vehicles for you need insured:
How many deliveries / errands / job sites per day:
Do you haul or deliver for:	Self   For Hire   No Hauling
If hauling, what specifically do you haul?
Liability Limits	-- choose -- $100,000 CSL $300,000 CSL $500,000 CSL $750,000 CSL $1,000,000 CSL
Uninsured Motorist Limits	-- choose -- $50,000 $100,000 $500,000 $750,000 CSL $1,000,000
Underinsured Motorist Limits	-- choose -- $50,000 $100,000 $500,000 $750,000 CSL $1,000,000
Medical Payments Limits	-- choose -- $1,000 $2,000 $5,000

Drivers Information
Drivers Full Name		Date of Birth	Marital Status	# Yrs Lic'd	Sex	Drivers License #	State Lic'd
1			- Choose - Single Married		M F
2			- Choose - Single Married		M F
3			- Choose - Single Married		M F
4			- Choose - Single Married		M F
5			- Choose - Single Married		M F

Accidents or Violations within the last 36 months
DR#	Date of incident	Accident or violation? (A or V)	Accident Details (including location and fault) or Violation Type	If Accident: Amount Paid
				Liability	Poperty Damage

Vehicle #1 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Loss Payee/Additional Insured (if any)
If Vehicle is Van, what type (Cargo,Mini,etc):
If Vehicle is Pick-up truck, do you have:	Ball at Bumper  Goseneck  Fifth Wheel  Ball in Bed  Trailer Hitch
Does Vehicle have:	Air Bag   Anti theft devices   Anti lock brakes
Collision Deductible wanted:	-- choose -- $250 $500 $1,000 $2,000 $3,000
Comprehensive Deductible (fire,theft,glass,etc):	-- choose -- $250 $500 $1,000 $2,000 $3,000

Vehicle #2 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Loss Payee/Additional Insured (if any)
If Vehicle is Van, what type (Cargo,Mini,etc):
If Vehicle is Pick-up truck, do you have:	Ball at Bumper  Goseneck  Fifth Wheel  Ball in Bed  Trailer Hitch
Does Vehicle have:	Air Bag   Anti theft devices   Anti lock brakes
Collision Deductible wanted:	-- choose -- $250 $500 $1,000 $2,000 $3,000
Comprehensive Deductible (fire,theft,glass,etc):	-- choose -- $250 $500 $1,000 $2,000 $3,000

Vehicle #3 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Loss Payee/Additional Insured (if any)
If Vehicle is Van, what type (Cargo,Mini,etc):
If Vehicle is Pick-up truck, do you have:	Ball at Bumper  Goseneck  Fifth Wheel  Ball in Bed  Trailer Hitch
Does Vehicle have:	Air Bag   Anti theft devices   Anti lock brakes
Collision Deductible wanted:	-- choose -- $250 $500 $1,000 $2,000 $3,000
Comprehensive Deductible (fire,theft,glass,etc):	-- choose -- $250 $500 $1,000 $2,000 $3,000

Remarks & Additional Information

Reporting Method
How would you like to receive your free Truck Insurance quote?	U.S.Postal E-mail Fax Phone

 

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