Hollingsworth Insurance Services

 
Commercial
Automobile
Insurance Application		   We would like to provide you with a free, no-obligation commercial automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

Agent Information
* Required Field
* Agent Name:
* Phone #:   * Fax #:
* Email Address:
  (Note: A copy of this submision will be sent to the email
  address entered in this field, so please enter correctly)


General Information
* Required Field
* Name of Insured:
* Address:
* City:   * State:   * Zip:
* Insured's Phone:   * Email Address:
* Garaging Location:   Check here if same as above address.
* Address:
* City:   * State:   * Zip:
* Business Type: Corporation   LLC   Individual   Other:
* Number of years in business:
* Please give a description of your business operations below:
* Does the risk have or plan
on having a US DOT#?: 		Yes   No     *If "Yes", US DOT#:
* Are all vehicles registered
to the company/corp? 		Yes   No     *If "No", who are they registered to?:
* Are vehicles used for
personal use? 		Yes   No
* If "Yes", please descirbe below:
* Are all the vehicles this entity
owns included in this quote request? 		Yes   No
* If "No", please advise why:


Driver Information
You can list up to 5 drivers on this form... reuse this form multiple times for additional drivers
* Driver Name
* Drivers License #
* State Licensed
* Date of Birth


Coverage Information
* Required Field
* Liability Amount (csl):
* Uninsured Motorist - Bodily Injury (csl):
* Uninsured Motorist - Property Damage: Yes   No
* Medical:
* Hired Auto: Yes   No
* Non-Owned Auto: Yes   No
* Comprehensive Deductible: Yes   No       If "Yes",
* Collision Deductible: Yes   No       If "Yes",


Vehicle Information
You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles
* Required Field
AUTO
#1
*Year
*Make
*Model
*VIN #
*Gross Vehicle Weight
*Cost New
*Radius
(in miles, one way)
*Vehicle Use
lbs.
$
*Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
* Required Field (only if including an additional auto)
AUTO
#2
*Year
*Make
*Model
*VIN #
*Gross Vehicle Weight
*Cost New
*Radius
(in miles, one way)
*Vehicle Use
lbs.
$
*Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
* Required Field (only if including an additional auto)
AUTO
#3
*Year
*Make
*Model
*VIN #
*Gross Vehicle Weight
*Cost New
*Radius
(in miles, one way)
*Vehicle Use
lbs.
$
*Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
* Required Field (only if including an additional auto)
AUTO
#4
*Year
*Make
*Model
*VIN #
*Gross Vehicle Weight
*Cost New
*Radius
(in miles, one way)
*Vehicle Use
lbs.
$
*Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
* Required Field (only if including an additional auto)
AUTO
#5
*Year
*Make
*Model
*VIN #
*Gross Vehicle Weight
*Cost New
*Radius
(in miles, one way)
*Vehicle Use
lbs.
$
*Please describe in detail what the vehicle is used for: 
If commodity is hauled, please explain:

 
Loss Information
* Required Field
  *How many losses have there been in the last 3 years?       (If any, please explain below)


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.


Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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