Commercial Auto Quote We are currently doing business in Florida and Georgia,

. Agent or Location Agent or State or County Georgia - All Counties Florida : Hillsborough County Manatee County Marion County Sarasota County Polk County Pinellas County Pasco County Hernando County Citrus County Taylor County Levy County Other FL County Agents L Brunoforte C Kazor M Petruccelli C Decker R DePirro W Poore A Giambrone E Reyes C Robson A Zyndorf Your Name: Mr. Mrs. Ms.   Address: City: County: State:    Zip:  Home Phone: Work Phone: Cell Phone: e-mail Address: Do you own a business? Yes No Type of business: Date Business Established: Dun & Bradstreet Listed Business Name: Present Auto Liability Company How Long Insured? Expiration Date Number of Drivers in Company Owner/Partner/CEO personal Credit History Name: Date of Birth: Social Security Number:     Driver Information Name Birth Date Marital Status # of Accidents in last 3 years # of Violations in last 3 years List Violations and Dates Filings Required? List Type January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Single Married Yes No Vehicle Information Commercial Usage: Describe Use of Vehicle Any Personal Use? Year Make Model Gross Vehicle Weight (not registered weight) No. of Axles or Passengers Radius of Operation Vehicle Stated Value VIN Garaging Zip Code Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300) Yes No 50 100 200 300 500 Unlimited Long haul Trucking 1-4 Power Units (over 300)   Coverage Information Coverage Type Auto 1 Auto 2 Auto 3 Auto 4 Auto 5 Auto 6 BI 15/30 25/50 50/100 100/300 250/500 15/30 25/50 50/100 100/300 250/500 15/30 25/50 50/100 100/300 250/500 15/30 25/50 50/100 100/300 250/500 15/30 25/50 50/100 100/300 250/500 15/30 25/50 50/100 100/300 250/500 PD 10,000 25,000 50,000 100,000 10,000 25,000 50,000 100,000 10,000 25,000 50,000 100,000 10,000 25,000 50,000 100,000 10,000 25,000 50,000 100,000 10,000 25,000 50,000 100,000 UM None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 UIM None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 None 15/30 25/50 50/100 100/300 Medical Payments None 2,000 5,000 10,000 None 2,000 5,000 10,000 None 2,000 5,000 10,000 None 2,000 5,000 10,000 None 2,000 5,000 10,000 None 2,000 5,000 10,000 Comprehensive (or F&T w/CAC None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 Collision None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 None 100 250 500 1,000 On-Hook Towing Non-Trucking (Bobtail) Glass Acc Death   Comments