Commercial Auto Quote Form

YOUR WHOLESALE INSURANCE SOLUTION

- Step 1 of 11

GET STARTED

Do you have completed Acords (125,127,137)? *

What is the zip code of your customer's primary business location? *

Expiring/Estimated Premiums

Please describe your customer's business operations.

SIC/NAICS Codes are helpful.

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RATING STATE

Rating State *

Policy Form/Type

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AGENCY/BROKERAGE INFORMATION

Are you an MGA Preferred Agency Member? *

Would you like more information on the MGA Preferred Agency Network? *

Visit MGA Preferred Agency Network

Agent/Broker Name *

First

Last

Agency/Brokerage Name *

Agency/Brokerage Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

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YOUR CUSTOMER'S BUSINESS INFORMATION

What is the name of your customer's business? *

What is the customer's business address? *

Address Line 1

Address Line 2

City

State

Zip Code

Your customer's physical business address.

What year was your customer's business started? *

Federal Tax ID/SSN

What is the legal structure of your customer's business? *

Does your customer's business have a DBA ('Doing Business As')? *

What Is your customer's business DBA ('Doing Business As')?

Does your customer's business have a website? *

What is the website address for your customer's business?

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YOUR CUSTOMER'S BUSINESS OWNER/CONTACT INFORMATION

Your customer's name. *

First

Last

Your customer's contact phone number. *

Customer's email address. *

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GENERAL POLICY INFORMATION

Is your customer's business currently insured? *

Policy Status *

Requested Effective Date of Policy

Current insurance carrier. *

Current premium amount paid.

Reason Policy Expired *

Previous Insurance Carrier *

Previous premium amount paid.

Has your customer's business had any claims? *

Claims include fire, burglary, flooding, vandalism, etc.

Number of claims in past 3-5 years

Number of full time employees. *

Number of part time employees. *

What are the gross receipts for your customer's business?

What is the annual revenue for your customer's business? *

Does your customer or your customer's business own their building? *

Target Premium

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VEHICLES INFORMATION

Do you have a multiple-vehicle list to upload? *

Year *

Make *

Model *

Cost New

VIN

Multiple Vehicles List

If you have multiple vehicles please upload list here.

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DRIVER INFORMATION

Do you have a multiple-drivers list to upload? *

Name *

First

Last

Gender

Marital

Birthdate *

License State *

License Number *

Multiple driver list

If you have multiple drivers please upload list here.

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COVERAGE FOR YOUR BUSINESS AUTO

Liability limit *

Un-Insured (UM) limit *

UM Prop damage limit *

Medical limit *

Comprehensive *

Collision *

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DOCUMENTS

Do you have all Acords on one file?

Acord 125 Form *

Acord 127 Form *

Acord 137 Form *

Acord 125,127 & 137 Forms *

Declarations Page of Expiring/Expired Policy

Supplementals

Loss Runs (3 years Preferred/5 years Hard to Place)

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CERTIFY INFORMATION

Certify *

I understand that the information provided herein is essential and material to the agency/broker relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.

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