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Commercial Auto
General Liability
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Description of Operations:
Business Premises
Do you lease, work from home, or own?
Lease
Own (this can also apply to commercial property)
Work from home
Office Address
Address
Building Information (Type unknown if not sure)
Square Footage of premise:
Year Built:
Construction type:
Roof Age:
Electric Age:
Plumbing Age:
HVAC Age:
Business personal property amount: (If you are a tenant include betterments & improvements) $
General Liability & Workers Compensation
Estimated Annual Gross Revenue:
Estimated Annual Payroll excluding owner(s):
List Owners Names & Annual payroll per owner:
Number of Employees
Eligibility Questions:
During the past three years has any company ever cancelled, declined, or refused to issue similar insurance to the application?
Yes
No
Has the insured or applicant had prior coverage?
Yes
No
Has the insured or applicant had any prior claims or losses in the last 3 years?
Yes
No
If Yes, please provide loss information
Has the applicant filed for bankruptcy in the past 5 years?
Yes
No
Commercial Auto
Enter Your USDOT#. If you do not have one, do you plan to obtain one within 60 days?
Driver(s) Information:
Date of birth:
Gender:
Marital Status:
Commercial Driver's License?
Yes
No
Year Licensed
License status
Valid
Suspended
Revoked
Learner/Operator Permit
License State
License Number
Vehicle(s) information:
Year, Make Model
Garaging Zip Code
VIN (17 digits)
Radius (50,100,200,300,500 or above)
Do you need full coverage on this vehicle? (comprehensive and collision)
If yes, current value:
Underwriting:
Are you currently insured?
Yes
No
Prior Carrier Name
How long have you been insured with this carrier?
Policy expiration date?
Any accidents/claims/moving violations for any driver listed in the past 5 years?
To help you find the best coverage & price please attach the following if available: Current insurance policy, driver's licenses, vehicle registrations and loss runs.
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Max. file size: 59 MB.
Additional Comments
Additional Comments
Please upload the following documents:
Insurance Declarations:
Details of existing policy coverages, limits, and terms.
Loss Runs:
A history of claims over the past several years, providing insight into previous losses and claims experience.
Driver's Licenses:
Identification for all drivers associated with the policy.
Vehicle Registrations:
Verification of vehicle ownership and registration details.
These documents help us assess coverage needs accurately and provide tailored recommendations.
File Upload
Max. file size: 59 MB.
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Customer Reviews
...they put their customers first, and they're incredibly nice people as well.
Andy B.
, Maryland
AA
At the same time he was very easy to work with, knowledgeable and professional!
Anya a.
, Rockville, MD
JF
The agent was very responsive.
Judith F.
, Mount Rainier, MD
MH
Good communication and prompt response to e-mails.
North Bethesda, MD
JC
What I liked the most was the fair price.
Jose C.
, MOUNT AIRY, MD
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