COMMERCE PROTECTIVE INSURANCE COMPANY ON-LINE QUICK QUOTE REQUEST FORM
**NOTE: This is not a Company application. Coverage is not bound with this submission. Coverage can only be bound by a Company Underwriter.
Formal Company applications may be required.

PRODUCER PASSWORD:

QUOTE DATE:

REQUESTED BY (AGENCY NAME):

CONTACT NAME:

CONTACT TELEPHONE:

CONTACT EMAIL:

APPLICANT NAME:

INDICATE Individual Partnership Corporation

Garaging Address:

Mailing Address (if different):

List Commodities being transported:

Any Hazmat?:

Maximum Radius travelled:

Normal Radius Travelled:

To what city?:

Do you haul for others? Please list entities:

Would you like a Blanket Additional Insured Included?

Federal or State permits?

Vehicle Schedule: (*trailer information must be complete)

Year	Make	Type	Original Cost	Stated Amount

**If more than 4 vehicles, please add to list at bottom of page.

Do you own or lease any vehicles not listed on this schedule?

Driver Schedule (Full time and part time)

Name	State	DOB	CDL Exp.	Accidents/Violations/Suspensions

**If more than 4 drivers, please add at bottom of page.

Please list Payroll for Exec Officers/Partners and Sales Personnel:

(is payroll limitation included?)

Terminal employees/mechanics:

Please list Carrier information with policy period for PAST 3 YEARS:

Carrier	Policy Period	# of losses	Total Paid

(if commercial insurance has not been carried for the full 3 years, submit trucking references in place)
Has a cancel or Non-renewal been issued in the past 3 years:

COVERAGE REQUESTED - "√" each coverage being requested for quotation

Auto liability Limits: $

Medical/FP Limits: $

UM/UIM: $

General Liability Limits (Per Occurrence): $ /(Aggregate): $

Physical Damage ( Comp/ Spec Perils/ Collision)

Deductible Choice:

Towing Limits ( 5,000/ 10,000/ 15,000)

Cargo Limits: $

Deductible Choice:

Please list any Additional Coverage or Endorsement requested:

ADDITIONAL VEHICLES AND/OR DRIVERS: