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California Insurance QUOTE
LIFE INSURANCE
LIFE INSURANCE
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Question
On-Line Commercial Vehicle Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Business Name
Street Address
City
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
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?
COMMERCIAL VEHICLE #1
If more than 2 vehicles, list in remarks or call us at: 800-646-2366
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 INFORMATION FOR UNITS #3-5:
(If none, Leave Blank)
VEHICLE #3
(List Year, Make, Model & Value)
VEHICLE #4
(List Year, Make, Model & Value)
VEHICLE #5
(List Year, Make, Model & Value)
VEHICLE #2 - #5 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
Send my quotation via:
E-Mail                  Fax
Regular Mail      Call me by Phone!
Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
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Simons Insurance Agency
CA License #0772640
12743 Bellflower Blvd. Downey, CA 90242
Toll Free: 800-646-2366
Local Phone: 562-803-9501
Fax: 888-346-2245
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