Business Auto Insurance Quote
ALC Risk Solutions
| Current Policy Information | |
| Insurance Company: | |
| Premium: | |
| Policy Expiration Date: | |
| Business Information | |
| Years In Business: | |
| Number of Locations | |
| Annual Gross Revenue | |
| Annual Payroll (estimated) | |
| Describe Business: | |
| Vehicle 1 Information | |
| Year: | |
| Make: | |
| Model: | |
| Number Of Doors: | |
| Primary Driver: | |
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VIN Number: (Optional, but will help us give you an accurate quote.) |
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| Comprehensive Deductible: | |
| Collision Deductible: | |
| Vehicle 2 Information | |
| Year: | |
| Make: | |
| Model: | |
| Number Of Doors: | |
| Primary Driver: | |
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VIN Number: (Optional, but will help us give you an accurate quote.) |
|
| Comprehensive Deductible: | |
| Collision Deductible: | |
| Vehicle 3 Information | |
| Year: | |
| Make: | |
| Model: | |
| Number Of Doors: | |
| Primary Driver: | |
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VIN Number: (Optional, but will help us give you an accurate quote.) |
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| Comprehensive Deductible: | |
| Collision Deductible: | |
| Limit Liability For Automobile | |
| Combined Single Limit: | |
| Uninsured Motorist: | |
| Hire and Non-Owned Auto?: | |
| Driver Information | ||||
| Driver 1 | Driver 2 | Driver 3 | ||
| Name: | ||||
| Length of Time At Job: | ||||
| DOB: | ||||
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Driver Tickets and Accidents Please describe any traffic incidents for the drivers above that invovle tickets and/or accidents (i.e. Speeding, DUI, Accidents, etc). |
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Driver 1 Driver 2 Driver 3 |
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| Additional Underwriting Questions | |
| Have you been cancelled, non-renewed oe declined for insurancein the past 3 years? | |
| Has the applicant had a foreclosure, repossession, bankruptcy, judgment or lien in the past 5 years? | |
| Has the applicant been involved in any lawsuits, or had any judgements or leins against them in the past 5 years? | |
| Are any other business operations owned by the applicant, or any owners of the applicant company? | |
| Do you have a formal vehicle safety program or fleet management program? | |
| Do you check employees' Motor Vehicle Records prior to hire? | |
| Are any vehicles Altered, Customized or Specially Equiped? | |
| If yes, Please explain and give approximate replacement costs: | |
| Would you like ALC Risk to quote any other lines of insurance for you? | |
| What other lines of insurance would you like a quote for? | |
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Additional Information Please list additional vehicles, drivers or other pertinent information to help expidite the underwriting process. |
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