Commercial Auto Insurance – Linwood Forest Insurance Group

Do you currently have commercial auto insurance?
- Yes
- No
Who do you have car insurance with now?
How many years have you been with this car insurance company?
- Less than 1 year
- 1 Year
- 2 Years
- 3 Years or more
How much are you paying annually?
When does current commercial auto insurance expire?
MM DD YYYY

Are vehicle garaged at mailing address?
- Yes
- No
Vehicle Garaging Address
List all Vehicle's to be insured
VIN# of Car Physical Damage? Deductible? Max Radius
Driver(s) Information - List All Drivers
Full Name Date Birth Issued State Driver License # Date of Defensive Driving Course Completion
Requested Liability Limits
- 300,000 CSL
- 500,000 CSL
- 1,000,000 CSL

Has your business ever had any commercial auto claims?
- Yes
- No
List all claims within last 5 years, this will be verified with required loss runs
Date of Claim Description of Claim Payout Amount Open/Closed
Have you or any driver(s) had their license suspended because of a moving violation?
- Yes
- No
Please list all driver's with license suspensions, this will be verified with MVR.
Full Name Date Suspended (MM/YYYY)
Have you or any driver(s) been convicted of a DUI or DWI?
- Yes
- No
Please list all driver's with DUI or DWI, this will be verified with MVR.
Full Name Date Convicted (MM/YYYY)
Have you or any driver(s) had a speeding violation 85 mph or more in last 3 years?
- Yes
- No
Please list all driver's with speeding violations, this will be verified with MVR
Full Name Date of Violation (MM/YYYY)

Full Name	Date Birth	Issued State	Driver License #	Date of Defensive Driving Course Completion

MM	DD	YYYY

VIN# of Car	Physical Damage?	Deductible?	Max Radius

Date of Claim	Description of Claim	Payout Amount	Open/Closed