Home

 

 Members Add/Delete Online Form
Partners
Resources
Start Up
Insurance
F.A.Q
Quick Quote
Contact Us


Quick Quote

For an Insurance Quick Quote, please fill out the form below, and someone will contact you.

*Your Name:

  
 *Company Name:  
*Address:  
*City:  
*State:  
*Zip Code:  
*Telephone:  
Fax:  
*Contact:  
*Email:  
*Title:  
*FEDERAL ID #:  
*Owner 1:  
*% of Ownership:  
Owner 2:   (if applicable)
% of Ownership:   (if applicable)
Owner 3:   (if applicable)
% of Ownership:   (if applicable)
Owner 4:   (if applicable)
% of Ownership:   (if applicable)
*Type of Business  
*Year Business Started:  
*Type of Units:  
     

Give brief explanation of your Professional Experience
Narrative:

 

 

 

 

  
*# of rental units now:   (*leave blank if start up)
*# expected:  
*Highest to lowest vehicle value:   to
*Year range of vehicles:   to
*Anticipated Start Date:  
Found Us Where?  

If other, please state:

 

  
*Describe rental customer:
(i.e., Insurance Replacement, Warranty, Service, Walk-in, etc.)		  
*Describe Security for Dealership:
(i.e., Fence, Gate, Security Alarm, Cameras, etc.)		  
     

DRIVER LIST
Please list ALL employees and non-employees who drive lot cars.
Show whether a vehicle is furnished for their regular use and, if so, whether they are covered by a personal auto policy.
Please provide a 3 year history for any accidents or violations.

NOTE: THIS FORM MUST BE COMPLETED AND FORWARDED TO COMPANY WITH APPLICATION.
     
   Driver 1 Information  
  Full name:
  Driver's License #:
  State Issued: (Please abbreviate, i.e., GA)
  Date of Birth: Example: 00-00-0000

Job Title or Relationship w/Insured:

  Full/Part Time: Full Time Part Time
  Regular Use: YES NO
  Personal Auto Ins. Co. & Policy #:
 

 
  Accidents and Violations:

 
     
   Driver 2 Information  
  Full name:
  Driver's License #:
  State Issued: (Please abbreviate, i.e., GA)
  Date of Birth: Example: 00-00-0000

Job Title or Relationship w/Insured:

  Full/Part Time: Full Time Part Time
  Regular Use: YES NO
  Personal Auto Ins. Co. & Policy #:
 

 
  Accidents and Violations:

 
     
   Driver 3 Information  
  Full name:
  Driver's License #:
  State Issued: (Please abbreviate, i.e., GA)
  Date of Birth: Example: 00-00-0000

Job Title or Relationship w/Insured:

  Full/Part Time: Full Time Part Time
  Regular Use: YES NO
  Personal Auto Ins. Co. & Policy #:
 

 
  Accidents and Violations:

 
     
   Driver 4 Information  
  Full name:
  Driver's License #:
  State Issued: (Please abbreviate, i.e., GA)
  Date of Birth: Example: 00-00-0000

Job Title or Relationship w/Insured:

  Full/Part Time: Full Time Part Time
  Regular Use: YES NO
  Personal Auto Ins. Co. & Policy #:
 

 
  Accidents and Violations:

 
     
   Driver 5 Information  
  Full name:
  Driver's License #:
  State Issued: (Please abbreviate, i.e., GA)
  Date of Birth: Example: 00-00-0000

Job Title or Relationship w/Insured:

  Full/Part Time: Full Time Part Time
  Regular Use: YES NO
  Personal Auto Ins. Co. & Policy #:
 

 
  Accidents and Violations:

 
     
     
Other Comments/Questions:

 

 

 		  


Thank You for your Inquiry
     



1-800-348-3624