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For California residents only

COMMERCIAL TRUCK vs. PERSONAL TRUCK (Why should I put my trucks on a Commercial Policy?)

Click the SUBMIT button to receive your free quote. Remember should you wish to speak to a live person you can always phone us at 888-MY-INS-GUY/888-694-6748 (M-F 8:00 - 5:00).

Applicant Information
Contact Name
Business Name
E-mail
Street Address
City
County
State
Zip Code
Contact Phone
FAX
Social Security or FEIN:
Birthdate:

Contractor Rating Information
Business Web-Site
Describe Type of Contractor
Contractors License Number
Legal Entity
Years in business
Any bankruptcies or tax liens in past 3 years? Yes No
Requested Effective Date:
Are you currently insured? Yes No
Have you been insured for the past 12 months with no lapse in coverage? Yes No
Current Policy Number:
Current Insurance Carrier:
How many job sites/stops per day:
Liability Limits
Uninsured Motorist Limits
Medical Payments Limits

Drivers Information
Drivers Full Name Date of Birth Marital
Status		 # Yrs Lic'd Sex Drivers
License #		 State
Lic'd
1 M F
2 M F
3 M F
4 M F
5 M F

animated truck crashing


Accidents or Violations within the last 36 months
DR# Date of
incident		 Accident or
violation?
(A or V)		 Accident Details (including location and fault)
or Violation Type		 If Accident:
Amount Paid
Liability Poperty Damage

Vehicle #1 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Does Vehicle have: Air Bag   Anti theft devices   Anti lock brakes  
Collision Deductible wanted:
Comprehensive Deductible (fire,theft,glass,etc):

Vehicle #2 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Does Vehicle have: Air Bag   Anti theft devices   Anti lock brakes  
Collision Deductible wanted:
Comprehensive Deductible (fire,theft,glass,etc):

Vehicle #3 Information
VIN #
Year
Make
Model
Vehicle Description
Purchase Price
"Stated" Amount
Garaging Zip Code
Maximum miles driven one-way from garaging zip code
Gross Vehicle Weight (Fully Loaded)
Detailed use of Vehicle
Does Vehicle have: Air Bag   Anti theft devices   Anti lock brakes  
Collision Deductible wanted:
Comprehensive Deductible (fire,theft,glass,etc):

Remarks & Additional Information

Reporting Method
How would you like to receive
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Home Page | E-Mail

 Gary Jones Insurance Agency  CA License #0E22842  insure@iinsureit.com
 508 Main Street  310-615-0940 Phone  888-MY-INS-GUY
 El Segundo, CA 90245  310-615-0994 Fax  888-694-6748