Countywide Insurance Agency - Commercial Automobile Insurance Quote Form

General Information

	Name of Insured:
	Address:
	Address (Line 2):
	City:
	State:
	Zip:
	Business Phone:
	Business Fax:
	E-mail
	Garaging Address (if different than above):
	Garaging Address (Line 2):
	City:
	State:
	Zip:


Coverage Information

	Liability Amount:
	Uninsured Motorist - Bodily Injury:
	Uninsured Motorist - Property Damage:	YesNo
	Medical:
	Hired Auto:	YesNo
	Non-owned Auto:	YesNo
	Comprehensive Deductible:	YesNo Amount:
	Collision Deductible:	YesNo Amount:


Vehicle Information

	Vehicle #1	Year:
		Make:
		Model:
		VIN:
		Vehicle Weight:
		Cost New:
		Vehicle Use:
		Describe, in detail, what the vehicle is used for:


	Vehicle #2 (if applicable)	Year:
		Make:
		Model:
		VIN:
		Vehicle Weight:
		Cost New:
		Vehicle Use:
		Describe, in detail, what the vehicle is used for:


	Vehicle #3 (if applicable)	Year:
		Make:
		Model:
		VIN:
		Vehicle Weight:
		Cost New:
		Vehicle Use:
		Describe, in detail, what the vehicle is used for:


	Vehicle #4 (if applicable)	Year:
		Make:
		Model:
		VIN:
		Vehicle Weight:
		Cost New:
		Vehicle Use:
		Describe, in detail, what the vehicle is used for:


	Vehicle #5 (if applicable)	Year:
		Make:
		Model:
		VIN:
		Vehicle Weight:
		Cost New:
		Vehicle Use:
		Describe, in detail, what the vehicle is used for:



Loss Information

	# of Losses in the Last 3 yrs:
	Please Explain:


Comments

If there is anything else we should know or if you didn't have enough space above please include it here: