Business Auto Insurance | LAJ Insurance Agency

Business Name:

Email:

Phone:

Type of business:

How many vehicles:

What are the vehicles being used for:

Do you have a DOT #:

Owner/s name:

Owners DOB, DL#:

Owners Marital Status:

How many Drivers:

Drivers name, DOB, DL #, marital status. (Attach Spreadsheet or Pics of DL):

Attach Spreadsheet or Pics of DL

Does anyone have a CDL:

VIN #’s

Attach Spreadsheet of VINS

Year, Make & Model:

Any permanently attached equipment?

Anyone have any accidents, claims or violations in the past 4 years:

Annual Mileage:

Furthest one-way distance:

Do you cross into other states:

Garaged State & Zip, Are employees taking the car home:

Financed, Lease or Own:

Original Owner:

Policy Limits:

Comprehensive:

Collision:

Deductibles: (100, 250, 500, 750, 1000, 2500)

Rental or Roadside:

Hired auto or ENOL (employer non-owned auto liability):

Do you need to add any Additional Insureds:

Do you need any state/federal filings?