176 Main Street • East Windsor, Connecticut 06088 USA
Phone: 860-623-9961 • Fax: 860-623-0061
176 Main Street
•
East Windsor, Connecticut 06088 USA
Phone: 860-623-9961
•
Fax: 860-623-0061
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Business Auto Quote - Connecticut
Contact Information
Contact Name:
Company Name:
Address:
City:
Zip Code:
Business Phone Number:
Preferred Time to Call:
AM
PM
Business Fax Number:
E-mail Address:
About Your Business
Please give a detailed description of your business and its operations.
Class of Business:
Retail
Wholesale
Retail or Wholesale
Service
Trucking
Concessions
Contractor
Current Auto Insurance Information
Company Name:
Policy Expiration:
Premium Amount:
$
Policy Term:
6 Months
1 Year
Number of Years Insured:
Vehicle and Deductible Information
This includes all cars your company currently owns or leases.
Vehicle
Year
Make
Model
VIN #
1
Comprehensive Deduct.
Collision Deductible
Towing
Rental Reimbursement
None
$100
$250
$500
$750
$1000
Over $1000
None
$100
$250
$500
$750
$1000
Over $1000
No
Yes
No
Yes
Vehicle
Year
Make
Model
VIN #
2
Comprehensive Deduct.
Collision Deductible
Towing
Rental Reimbursement
None
$100
$250
$500
$750
$1000
Over $1000
None
$100
$250
$500
$750
$1000
Over $1000
No
Yes
No
Yes
Vehicle
Year
Make
Model
VIN #
3
Comprehensive Deduct.
Collision Deductible
Towing
Rental Reimbursement
None
$100
$250
$500
$750
$1000
Over $1000
None
$100
$250
$500
$750
$1000
Over $1000
No
Yes
No
Yes
Vehicle
Year
Make
Model
VIN #
4
Comprehensive Deduct.
Collision Deductible
Towing
Rental Reimbursement
None
$100
$250
$500
$750
$1000
Over $1000
None
$100
$250
$500
$750
$1000
Over $1000
No
Yes
No
Yes
Driver Information
Driver
Name
License Number
State
Date of Birth
SSN
1
Driver
2
Driver
3
Driver
4
Liability for
All
Cars
Bodily Injury and Property Damage
Bodily Injury:
$25,000 / $50,000
$50,000 / $100,000
$100,000 / $300,000
$250,000 / $500,000
Property Damage:
$25,000
$50,000
$100,000
$250,000
$500,000
Uninsured Motorist:
$25,000 / $50,000
$50,000 / $100,000
$100,000 / $300,000
$250,000 / $500,000
Single Limit
Single Limit:
$50,000
$100,000
$250,000
$500,000
Med Pay
Med Pay:
$1,000
$2,000
$5,000
Violations or Accidents
Describe Any Violations or Accidents You've Had in the Past 3 Years
Violation
Date
Description
1
Violation
2
Violation
3
Violation
4
Comments and/or Questions
Please note that no coverage is in effect until bound by an insurance carrier. This is a request for a quote, not a guarantee of insurance.
