Mathes Insurance Group - Commercial Auto Quotation Form

Commercial Auto
Insurance Quote Form

When filling out the Commercial Auto Insurance Quote Form below, be sure to fill in all of the Information in the RED Sections. If you do not fill out this required information, your form will not be processed.

Mathes Insurance Group is licensed to sell insurance in the State of Iowa. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will be unable to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Mathes Insurance Group accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

General Information

Name of Business:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	( )
Fax:	( )
Best time to call:	AM PM

Current Insurance Company (not agency)

Company Name:
Policy Exp. Date:	/ /

What type of coverages do you currently have:
Bond Commercial Auto Commercial Liability Commercial Property	Commercial Umbrella Directors & Officers Liability Disability Group Health	Group Life Professional Liability Workers' Compensation Other

About Your Business:

# of full-time employees	# of part-time employees	How long in business	How many locations	Annual Sales
		yrs.		$

Please give a brief description of your business and clientel:

Vehicle Information:

(include all cars you or your business owns or leases)

Car #1	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #1
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip: Vehicle Used for:

Vehicle Information:

(include all cars you or your business owns or leases)

Car #2	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #2
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip: Vehicle Used for:

Vehicle Information:

(include all cars you or your business owns or leases)

Car #3	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #3
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip: Vehicle Used for:

Vehicle Information:

(include all cars you or your business owns or leases)

Car #4	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #4
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip: Vehicle Used for:

Vehicle Information:

(include all cars you or your business owns or leases)

Car #5	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #5
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip: Vehicle Used for:

Driver Information:

(including all licensed drivers in your Business)

Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Completed		# of Yrs. Licensed
Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Drivers Education Course	Accident Prevention Course	# of Yrs. Licensed
		Self		M F	M S	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N

Vehicle Use:

(including all licensed drivers in your Business)

Driver's Name	% of Vehicle Use
Driver's Name	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4	Vehicle #5

Driver History

If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
Yes No
If yes, please answer the following:

Driver	Date	Type of Conviction	Time	Fines	Speed Over Limit