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Company Contact Information
Company
*
:
Address
*
:
City
*
:
State
*
:
Zip
*
:
Contact First Name
*
:
Contact Last Name
*
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Contact Email
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Phone
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Commercial Vehicles
Year
Make
Model
Vin#
Chassis
Air Bag
ABS
1
*
*
*
*
2WD
4WD
2
2WD
4WD
3
2WD
4WD
4
2WD
4WD
5
2WD
4WD
Vehicle Operators
Name
SSN
DOB
DL#
Exp.
1.
*
*
*
*
*
2.
3.
4.
5.
Deductibles & Options
Combined Single Limit of Bodily Injury and Property Damage:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
$ 65,000
$300,000
$600,000
$1 Million
$ 65,000
$300,000
$600,000
$1 Million
$ 65,000
$300,000
$600,000
$1 Million
$ 65,000
$300,000
$600,000
$1 Million
$ 65,000
$300,000
$600,000
$1 Million
Uninsured and Underinsured Motorist Coverage
(Bodily Injury and Property Damage Split Limits)
:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
50/100/15
100/300/50
50/100/15
100/300/50
50/100/15
100/300/50
50/100/15
100/300/50
50/100/15
100/300/50
Collision Deductible:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
$250
$500
$1000
$250
$500
$1000
$250
$500
$1000
$250
$500
$1000
$250
$500
$1000
Comprehensive Deductible:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Zero
$100
$250
$500
Zero
$100
$250
$500
Zero
$100
$250
$500
Zero
$100
$250
$500
Zero
$100
$250
$500
Rental Reimbursement:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
$15 Per Day
$30 Per Day
$15 Per Day
$30 Per Day
$15 Per Day
$30 Per Day
$15 Per Day
$30 Per Day
$15 Per Day
$30 Per Day
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