The Lette Insurance Agency: Commercial Automobile Insurance Quote Form

Commercial Auto Insurance Quote

We would like to provide you with a free, no-obligation commercial auto insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Insured:
Address:
City:	State: Zip:
Business Phone:	Fax Number:
Email Address:
Garaging Address (type "same" if same as above):
City:	State: Zip:

Coverage Information

Liability Amount (csl):

Uninsured Motorist - Bodily Injury (csl):

Uninsured Motorist - Property Damage: Yes No

Medical:

Hired Auto: Yes No

Non-Owned Auto: Yes No

Comprehensive Deductible: Yes No If "Yes",

Collision Deductible: Yes No If "Yes",

Vehicle Information

You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles

AUTO
#1 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#2 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#3 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#4 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#5 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

Loss Information

How many losses have there been in the last 3 years? (If any, please explain below)

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.