docAUI Commercial Auto Easy Quote
download 
Report Transcription
AUI Commercial Auto Easy Quote
AUI Commercial Auto Easy Quote **PLEASE NOTE: This sheet is no substitute for any required binding documentation** Please complete and fax to 866-409-3367 Date: ______________ Name: __________________________________________ DBA: ____________ Mailing Address: __________________________________________________________________ Garage Address: __________________________________________________________________ Phone: _____________________ Contact Name: ________________________________________ Email Address: ______________________________ FEIN #: ______________________________ SS#: ________________ Yrs. in Business __________________ Commodities: _____________________________________________________________________ _________________________________________________________________________________ Radius (City/States Traveled): ________________________________________________________ _________________________________________________________________________________ For Hire? ______________ If No, Who are You Hauling for? _________________________________ Liability:__________________________ PIP: __________________________ UM: __________________________ MC#: __________________________ DOT#:_________________________ Hired & Non-Owned: _____________________ Physical Damage: _______________________ (dedc) Cargo: __________________________ Reefer: ______Yes ______No Trailer Interchange: ______________________ Additional Insureds: _________________________________________________________________ _________________________________________________________________________________ 800 Oak Ridge Turnpike, A-1000 | Oak Ridge, TN 37830 888-376-9633 | www.appund.com 01-09-12 Previous 3 Years of Coverage Years Company __________________________ _____________________________________________ __________________________ _____________________________________________ __________________________ _____________________________________________ Losses (provide runs for the Last Three Years) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Drivers Name DOB License# & State CDL Issue Date ____________________________________ _____________________________________ ____________________________________ _____________________________________ ____________________________________ _____________________________________ Vehicles Yr/Make/Model GVW VIN# Value ____________________________________ _____________________________________ ____________________________________ _____________________________________ ____________________________________ _____________________________________ Agency Information Name: __________________________________________________________________________ Physical Address: __________________________________________________________________ Phone: _______________ Fax: ____________________ Email: _____________________________ Producer Code: _________________________ 800 Oak Ridge Turnpike, A-1000 | Oak Ridge, TN 37830 888-376-9633 | www.appund.com 01-09-12
