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Steve
Stephen B. Groton -- Insurance Agent and Broker - Free Truck Insurance Quote
CA License Number 0816642
626-584-6303

Commercial Vehicle
Insurance Quote Request Form
One Simple Form - takes only a few minutes!

Basic Information:
Your Name:
Business Name:
Street Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Currently Insured?
(If yes, list carrier, and # of years continuous. If no, type NONE)
 
Can You provide 3 Year Loss Runs from Prior Insurance Carrier?
(Some companies products require 3 year loss runs to qualify.)
Yes No
 
Do You Carry Workers Compensation Insurance?
Yes No
 
Who Maintains Your vehicles?
 
Describe the Use of Your Commercial Vehicles in Detail:
 
Type of Business?

DRIVER INFORMATION #1 (if more than two drivers, list in remarks)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Date of Hire: State & License#:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Citations
in last 3 years:
Number & Type of
MAJOR Citations
in last 3 years:
Radius of Operation
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?

DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Date of Hire: State & License#:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Citations
in last 3 years:
Number & Type of
MAJOR Citations
in last 3 years:
Radius of Operation
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?

COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks:
Year of vehicle: Make & Model:
Type (long haul trailer/tractor, tow-truck, bobtail, etc., etc.): Length in Feet:
Radius of operation: Value $:
List Special Coverages Needed, or Special Equipment to be covered:
VEHICLE #1 COVERAGES:
Limits of
Bodily Injury Liability:
State Required Limits Please
$1 Million
$750,000
$500,000
$300,000
$100,000
$60,000
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want PIP /
Medical Coverage?
Yes No   Uninsured /
Underinsured
  Motorists?
Yes No
COMMERCIAL VEHICLE #2:
Year of vehicle: Make & Model:
Type (long haul trailer/tractor, tow-truck, bobtail, etc.): Length in Feet:
Radius of operation: Value $:
List Special Coverages Needed, or Special Equipment to be covered:
VEHICLE #2 COVERAGES:
Limits of
Liability:
State Required Limits Please
$1 Million
$750,000
$500,000
$300,000
$100,000
$60,000
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want PIP /
Medical Coverage?
Yes No   Uninsured /
Underinsured
  Motorists?
Yes No
 
List Additional Vehicle Information or Additional Drivers Here:

Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone
Thank you for filling out this form COMPLETELY!

We respect your privacy! Every step has been taken to insure your privacy and security. It is our intent to release quote information only to you. We will not give your data to ANY other person, company, or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!


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