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Commercial Auto Insurance

Name of Company

Contact Person

First     Last  

Contact Number (with area code)

Fax Number (with area code)

Address

Street  

Suite Number  

City     St    Zip 

Email Address *

Web Address

SBCIA.com, Guiding your business in the right direction.

Who Referred You To Our Site?

If you selected Agent or Other, please indicate who

If you selected Search Engine, please indicate which one

SBCIA.com, Guiding your business in the right direction.

Nature of Business (please provide a detailed description)

Federal Employer ID#

Years in Business

Insurance History

Present Insurance Company

Loss History

Authorized Driver Info

Authorized Drivers

Driver's Name

TxDL #

Birth Date (mm/dd/yy)

Driver 1

Driver 2

Driver 3

Driver 4

For Additional Drivers

Moving Violations in Last 3 Yrs

0    1    2    3+

Please provide the date and a brief description of each violation.

Fleet Info

Make & Model

VIN

Year

Cost New

$

$

$

$

$

$

$

General Auto Info

With the exception of encumbrances, are any vehicles not solely owned by and registered to applicant?

Yes         No

Do over 50% of employees use their autos in the business?

Yes         No

Is there a vehicle maintenance program in operation?

Yes         No

Are any vehicles leased to others?

Yes         No

Are any vehicles customized, altered or have special equipment?

Yes         No

Are ICC, PUC, or other filings required?

Yes         No

Do operations involve transporting hazardous material?

Yes         No

Any hold harmless agreements?

Yes         No

Any vehicles used by family members?

Yes         No

Does applicant obtain MVR verificatoins?

Yes         No

Does applicant have a specific driver recruiting method?

Yes         No

Are any drivers not covered by workers compensation?

Yes         No

Any drivers have moving traffic violations?

Yes         No

Has agent inspected vehicles?

Yes         No

Additional Questions or Comments

      
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Southwest Business Insurance Agency, Inc. specializes in business insurance, financial and estate planning in Texas. sbcia.com is a product of Southwest Business Insurance Agency, Inc. Copyright 2002