Please provide the following information:

 

Artisan Contractors Commercial Auto / Vehicle Quote Request Form   YOUR PERSONAL DATA:
Your Name:
Business Name:
Street Address:
City:
State:	Select One Texas
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)
Type of Business: (Please be specific, and tell how vehicles are used.)

DRIVER INFORMATION #1 (if more than two drivers, list in remarks)
Name:		Birthdate:
Sex:		# Years U.S.  Auto License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?
DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S.  Auto License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?
If More than 2 Drivers, List Driver Name, Age, and Driving Record in each box below: Driver #3: Driver #4: Driver #5: Driver #6: Driver #7: Driver #8:

COMMERCIAL VEHICLE #1: Should you have more than 5 vehicles, please call us at 866-TEXAS-45. Toll Free:  866-839-2745
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Gross Vehicle Weight:		Cost New: $
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate rating)
VEHICLE #1 COVERAGES:
Limits of Liability:	$500,000 CSL $750,000 CSL $1 Million CSL
Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No	Uninsured   Motorists?	Yes No

 

COMMERCIAL VEHICLE #2:
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Gross Vehicle Weight:		Cost New: $
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate rating)
VEHICLE #2 COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No	Uninsured   Motorists?	Yes No
COMMERCIAL VEHICLE #3:
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Gross Vehicle Weight:		Cost New: $
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate rating)
VEHICLE #3 COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No	Uninsured   Motorists?	Yes No
COMMERCIAL VEHICLE #4:
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Gross Vehicle Weight:		Cost New: $
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate rating)
VEHICLE #4 COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No	Uninsured   Motorists?	Yes No
COMMERCIAL VEHICLE #5:
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Gross Vehicle Weight:		Cost New: $
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE ID# (highly suggested for accurate rating)
VEHICLE #5 COVERAGES:
(Limits of Liability Will Be Same as Vehicle #1)
Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Do you want Medical Coverage?	Yes No	Uninsured   Motorists?	Yes No

Send my quotation via:	E-Mail Fax Regular Mail Call Me by Phone

 

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