California Insurance

INSURANCE

COMMERCIAL AUTO INSURANCE

Fields marked (*) are mandatory.

General Information

Named Insured*

Corp. Name (DBA)*

Eff. Date*

Business Information

Mailing Address*

Primary Location*

Nature of Business*

Years in Business*

Phone Number

F.E.I.N.*

Current Policy Information

Canc/Non-Renewed/Decl. Last 3 years*

Yes

If Yes Explain

Current Premium

Current carrier

Losses last 3 Years*

Coverage

Liability Limit*

U/M Limit*

REJECr*

Yes

Medical Payments*

Yes

Limit*

Drivers

Driver #1 (Driver Name D/L#-State Years Licensed in State DOB Viol/Accs)*

Driver #2 (Driver Name D/L#-State Years Licensed in State DOB Viol/Accs)

Driver #3 (Driver Name D/L#-State Years Licensed in State DOB Viol/Accs)

Driver #4 (Driver Name D/L#-State Years Licensed in State DOB Viol/Accs)

Driver #5 (Driver Name D/L#-State Years Licensed in State DOB Viol/Accs)

Vehicles

Vehicle #1 (Year Make/Model Type GVW Current Value)*

Vehicle #2 (Year Make/Model Type GVW Current Value)

Vehicle #3 (Year Make/Model Type GVW Current Value)

Vehicle #4 (Year Make/Model Type GVW Current Value)

Vehicle #5 (Year Make/Model Type GVW Current Value)

Physical Damage*

Yes

Spec. Perils Deductible

Collision deductible

Radius of Operation(s)*

Filings Needed*

Yes

If Yes Explain

SR 22 Needed (if Yes Ineligible)*

Yes

Livery (Public of Private) Exposure (If Yes Ineligible)*

Yes

Remarks

The California Insurance
10568 MAGNOLIA AVE
# 117 ANAHEIM, CA 92804

Phone:
714-229-1322

Toll-Free:
800-998-2092

E-mail:
info@
thecaliforniainsurance.com