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COMMERCIAL AUTO QUOTE

WE PROVIDE INSURANCE COVERAGE FOR MINNESOTA ONLY
To obtain a FREE, no obligation quote for your commercial car, fill out the form below and we will contact you. If you prefer to give information over the phone, fill out the * areas only and we will give you a call, or print this out and mail or fax it to us.


Name: *
Address: *
City: *
State: *
ZIP: *
Home Phone: *
Email: *
Work Phone:
Cell Phone:
COMMERCIAL AUTO AND DRIVER INFORMATION
Many of the companies we represent require the following information prior to providing a firm quote. To provide an accurate quote we need to ask questions about yourself and members of your family. The information collected enables us to receive information from consumer reporting agencies, motor vehicle departments, and inspection services. This information is available to the insurance companies who provide the insurance rates used in the quoting process.
Liability Options:
Combined Single Limit (CSL)
Bodily Injury & Property Damage
300,000
500,000
1,000,000
 Comprehensive:
250
500
1000
None		 Collision
250
500
1000
None
If you have more than 5 Commercial Autos would you like an agent to contact you?
  Yes   No
Trucking Operations:
Type of cargo hauled:
Filing Required:   Yes   No
Do you operated in more than 1 state?:   Yes   No
Major cities entered:

COMMERCIAL CAR #1
Year:   Make:   Model:
Cost New:    Gross Vehicle Weight (GVW):
Vehicle Serial/Vin No:
Comprehensive coverage desired?   Yes   No
Collision coverage desired?   Yes   No
Drivers Name:    Age:
Years Of Experience:
Radius:   0-50   50-150   150-300   Unlimited
Violations in the past 3 years:   Yes   No
If Yes - Please provide the date and brief description of each violation:
Prior Carrier information:
Have you had any insurance claims, or received any payments of any type
from your insurance company? Please describe each claim:

COMMERCIAL CAR #2
Year:   Make:   Model:
Cost New:    Gross Vehicle Weight (GVW):
Vehicle Serial/Vin No:
Comprehensive coverage desired?   Yes   No
Collision coverage desired?   Yes   No
Drivers Name:    Age:
Years Of Experience:
Radius:   0-50   50-150   150-300   Unlimited
Violations in the past 3 years:   Yes   No
If Yes - Please provide the date and brief description of each violation:
Prior Carrier information:
Have you had any insurance claims, or received any payments of any type
from your insurance company? Please describe each claim:

COMMMERCIAL CAR #3
Year:   Make:   Model:
Cost New:    Gross Vehicle Weight (GVW):
Vehicle Serial/Vin No:
Comprehensive coverage desired?   Yes   No
Collision coverage desired?   Yes   No
Drivers Name:    Age:
Years Of Experience:
Radius:   0-50   50-150   150-300   Unlimited
Violations in the past 3 years:   Yes   No
If Yes - Please provide the date and brief description of each violation:
Prior Carrier information:
Have you had any insurance claims, or received any payments of any type
from your insurance company? Please describe each claim:

COMMERCIAL CAR #4
Year:   Make:   Model:
Cost New:    Gross Vehicle Weight (GVW):
Vehicle Serial/Vin No:
Comprehensive coverage desired?   Yes   No
Collision coverage desired?   Yes   No
Drivers Name:    Age:
Years Of Experience:
Radius:   0-50   50-150   150-300   Unlimited
Violations in the past 3 years:   Yes   No
If Yes - Please provide the date and brief description of each violation:
Prior Carrier information:
Have you had any insurance claims, or received any payments of any type
from your insurance company? Please describe each claim:

COMMERCIAL CAR #5
Year:   Make:   Model:
Cost New:    Gross Vehicle Weight (GVW):
Vehicle Serial/Vin No:
Comprehensive coverage desired?   Yes   No
Collision coverage desired?   Yes   No
Drivers Name:    Age:
Years Of Experience:
Radius:   0-50   50-150   150-300   Unlimited
Violations in the past 3 years:   Yes   No
If Yes - Please provide the date and brief description of each violation:
Prior Carrier information:
Have you had any insurance claims, or received any payments of any type
from your insurance company? Please describe each claim:
Comments:
  
Greater Insurance Service | 407 South Pokegama Avenue | Grand Rapids, MN 55744 | Tel: 218.327.1854
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