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starklogic
2021-06-22T12:11:30+00:00
Business Auto Quote
Small Commercial Business Auto Quote
This form is for Non-Fleet (4 power units or less). If there are 5 or more power units, it should be submitted via ACORD forms 125, 127 & 137.
Agency Information
Agency Name:
*
Contact Name:
*
Contact's Email
*
Agency Phone
*
Agency Fax
Insured's Information
Insured's Name
*
First
Last
Name of Business
*
Mailing Address
*
Street Address
Address Line 2
City
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State/Province/Region
ZIP Code
FEIN or SSN
Phone
*
Expiring Premium
Current Carrier
Expiration Date
*
MM slash DD slash YYYY
Detailed Description of the Insured's Operations
*
Entity Type
*
Corporation
LLC
Not For Profit
Partnership
Sole Prorpietor
Other
Other Entity Type
*
Years in Business
*
Number of Employees
*
Desired Coverage Limits
Garaging Location
*
Street Address
Address Line 2
City
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State/Province/Region
ZIP Code
Vehicles
Year
*
Make
*
Model
*
VIN
*
Cost New
*
Gross Vehicle Weight
*
Garaging Zip Code
*
Radius
*
<50miles
51-200miles
>200miles
Usage
*
Retail
Service
Commercial
Comprehensive Deductible
*
Yes
No
Collision Deductible
*
Yes
No
Click here to add a 2nd car
Add Car
Year
*
Make
*
Model
*
VIN
*
Cost New
*
Gross Vehicle Weight
*
Garaging Zip Code
*
Radius
*
<50miles
51-200miles
>200miles
Usage
*
Retail
Service
Commercial
Comprehensive Deductible
*
Yes
No
Collision Deductible
*
Yes
No
Click here to add a 3rd car
Add Car
Year
*
Make
*
Model
*
VIN
*
Cost New
*
Gross Vehicle Weight
*
Garaging Zip Code
*
Radius
*
<50miles
51-200miles
>200miles
Usage
*
Retail
Service
Commercial
Comprehensive Deductible
*
Yes
No
Collision Deductible
*
Yes
No
Click here to add a 4th car
Add Car
Year
*
Make
*
Model
*
VIN
*
Cost New
*
Gross Vehicle Weight
*
Garaging Zip Code
*
Radius
*
<50miles
51-200miles
>200miles
Usage
*
Retail
Service
Commercial
Comprehensive Deductible
*
Yes
No
Collision Deductible
*
Yes
No
Click here to add a 5th car
Add Car
Year
*
Make
*
Model
*
VIN
*
Cost New
*
Gross Vehicle Weight
*
Garaging Zip Code
*
Radius
*
<50miles
51-200miles
>200miles
Usage
*
Retail
Service
Commercial
Comprehensive Deductible
*
Yes
No
Collision Deductible
*
Yes
No
Drivers
*
Name
DOB
License State
License #
Liability Symbol:
*
1
7, 8, 9
Liability Limit
*
$100,000 CSL
$300,000 CSL
$500,000 CSL
$1 Million CSL
Uninsured/Underinsured Limit:
*
Yes
No
Medical Payments:
*
Yes
No
Comp/Collision Deductible
*
Choose One
$1,000
$2,500
$5,000
None
Additional Coverage
Towing
Rental
Additional Interests
*
Yes
No
Additional Interests Details
*
Name of interest
Additional interest address
Type of interest(Additional insured, Lienholder)
Relevent Vechicle(If Applicable)
Please indicate if you are interested in any of these other lines of business for this insured.
(Optional Lines available subject to eligibility)
Work Comp
Business Auto
Umbrella
EPLI
None
File Attachment
Please use this option to attach loss runs, photos, or any other documents that would be beneficial to the underwriter for quoting purposes. – Thanks –
Drop files here or
Select files
Max. file size: 32 MB.
Additional Remarks
You may be contacted by a commercial underwriter for additional information.
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