Commercial Auto Insurance Quote – Brockman Premier Insurance

Brockman Premier Insurance

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Company Name

DBA?

FEIN or SS#

Type

Contact Name

Mailing Address *

Garage Address (if different from mailing)

Email *

Phone number (format 123456789) *

Driver 1 – First & Last Name / DOB / Driver's License #

Drive Home?

yes
no

Owner or Employee?

owner
employee

Driver 2 – First & Last Name / DOB / Driver's License #

Driver 2 – Drive Home?

yes
no

Driver 2 – Owner or Employee?

owner
employee

Driver 3 First & Last Name / DOB / Driver's License #

Driver 3 – Drive Home?

yes
no

Driver 3 – Owner or Employee?

owner
employee

Driver 4 First & Last Name / DOB / Driver's License #

Driver 4 – Drive Home?

yes
no

Driver 4 – Owner or Employee?

owner
employee

Driver 5 First & Last Name / DOB / Driver's License #

Driver 5 – Drive Home?

yes
no

Driver 5 – Owner or Employee?

owner
employee

List an accidents or tickets – date, which driver, description of what happened, claim amount

Do you have written criteria on driver acceptability that includes…(check all that apply)

date of hire
dates of training
drug tests
Motor Vehicle Report (MVR) and date ordered / received
reference checks
disciplinary actions

Do you require prior experience driving the type of unit that employees will be driving in the business?

yes
no

If YES, how many years of experience are required?

Is there an accident investigation program?

Do you keep a file of accidents?

Number of employees that use their personal autos for your business:

Does management review maintenance logs and files?

Do drivers have procedures for reporting, repairing and servicing?

How do you enforce compliance with rules and/or procedures?

Vehicle 1 – year, make, model & vin *

Vehicle 2 – year, make, model & vin

Vehicle 3 – year, make, model & vin

Vehicle 4 – year, make, model & vin

Vehicle 5 – year, make, model & vin

Current insurance carrier & how many years with them? *

Any specifics on limits and/or coverage? *

Complete if non-owned auto coverage is desired:

What types of non-owned autos will be used? How will they be used? Total # of employees? How often will they be used? Will employees lease autos under the company? Will they lease autos under their own names for company business? Estimated annual mileage for all non-owned autos. Are employees required to have their own insurance / what liability limits are required?

Complete if hired auto coverage is desired:

Estimated total annual cost of hired autos? Does anyone lease autos in your name? What types of autos are hired? What is the average term of a lease? (any over 6 mths need to be listed as OWNED) Do you provide drivers to operate hired autos? Is there a written lease agreement? Will you be named as an additional insured on the lessor’s policy?

Notes