sr22 filing california insurance

sr22 filing california insurance
 
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sr22 filing california insurance
(This Page Last
Updated on
October 20, 2005)

 
  

 
On-Line Commercial Vehicles
Insurance Quote Request Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:
Street Address:
City:
State: (Must be California)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
How are your vehicles used?
(Please tell us the nature of your operation, the radius of ues, and other usage information, if any.)

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No If YES to SR22 filing, why needed?
(list accident/cite)

If You have more than 1 driver, continue with additional driver list below. If not, leave blank.

List employees' names, and other census data:
(If More Than 10 Employees, place call us to
receive a large group census form.)

Employee #2 Name:B-Date: Driving Record:
Employee #3 Name:B-Date: Driving Record:
Employee #4 Name:B-Date: Driving Record:
Employee #5 Name:B-Date: Driving Record:
Employee #6 Name:B-Date: Driving Record:
Employee #7 Name:B-Date: Driving Record:
Employee #8 Name:B-Date: Driving Record:
Employee #9 Name:B-Date: Driving Record:
Employee #10 Name:B-Date: Driving Record:
Employee #11 Name:B-Date: Driving Record:

VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD
$25/50 BI / 25 PD
$50/100 BI / 50 PD
$100/300 BI / 100 PD
$300,000 CSL
$500,000 CSL
$1 Million CSL
More than $1 Million CSL (list in remarks)
 
Comprehensive
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Uninsured Motorists
Coverage?		 YES NO
 
Rental Car &
Towing Coverage?		 YES NO
 
Medical and/or
PIP Coverage?		 YES NO
 

If You have more than 1 vehicle, continue with additional vehicle list below. If not, leave blank.

List Vehicles:
(If More Than 13 Vehicles, place call us to
receive a large business auto form.)

Vehicle #2 (Yr/Make/Model): Value: $
Vehicle #3 (Yr/Make/Model): Value: $
Vehicle #4 (Yr/Make/Model): Value: $
Vehicle #5 (Yr/Make/Model): Value: $
Vehicle #6 (Yr/Make/Model): Value: $
Vehicle #7 (Yr/Make/Model): Value: $
Vehicle #8(Yr/Make/Model): Value: $
Vehicle #9 (Yr/Make/Model): Value: $
Vehicle #10 (Yr/Make/Model): Value: $
Vehicle #11 (Yr/Make/Model): Value: $
Vehicle #12 (Yr/Make/Model): Value: $
 

Comments or Remarks:
(List additional drivers, autos, etc. here)

 
Tell us any other particulars about your insurance needs - special limits or coverage, past claim history, etc.:

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