Commercial Auto Insurance

At NEC Insurance Agency, Inc.  We put the power of the internet to work for you!  Please take a moment to answer the following questions. Remember, this information is needed to find the best rate for you, so please answer it as accurately and completely as possible..



1) Description of the business:    

2) What type of entity is your company?    

3) Please indicate the state in which your business is located:

4) Please indicate your total # of full-time employees:

# of Part Time Employees:

5) Please indicate your total annual revenue:

6) Do you currently have business auto insurance?  Yes No

If you are currently insured, please select your current insurance carrier:

If your provider is not listed above, please provide the company name here:

7) How many years have you had coverage with this company?

8) How many years have you had continuous coverage (With no lapse)?

9) If you do not have coverage please indicate when you would like a policy to go into effect:

10) Please indicate the number of automobiles you would like to insure:

11) Please indicate the number of Drivers you would like to insure:

Now, take a moment to tell us about the primary vehicles you wish to insure. Please list all other vehicles and their descriptions in the the other vehicles field.

Automobile Information :

1) Is the Vehicle Leased:  Yes No

Year:

Make:

Type:

2) VIN:

Please enter GVW:

3) 4-Wheel Drive?  Yes No

4)Anti-Lock Brakes (ABS)?  Yes No

5) Alarm Type?

6) Number of Air Bags?

7)Seat Belts?

8)Parking:

9) Annual Miles:

If new car, what is the MSRP:

10) Comprehensive Deductible:

11) Collision Deductible:

Principle place the vehicle will be garaged:

1) Street:          

2) City:                   

3) State:                

4) Zip Code:        

5) Additional Vehicles: If this is a Fleet Policy, Please contact us.

Driver Information: ( Company Officer )

1) Name on Drivers License: (Last, First MI)

2) Drivers License #:

3) State of Issue:

4) Social Security Number:

5)Date of Birth: [MM/DD/YYYY]

6) To get exact Quote, We have to run your Credit, Do you give us permission to do so ?  Yes No Just Estimate

7) Sex:  Male Female

8) Marital Status:

9) Occupation:

10) Years Licensed:

11) 6 hour accident prevention class?  Yes No

Driving History: 1st driver history. Has this driver had any ?

1) Any DUI or DWI in the Last 5 Years?  Yes No

2) Has your license been suspended in the last 5 years?  Yes No

or revoked?  Yes No

3) Number of moving violations in the last 4 years. (Speeding, Stop Sign, Etc.)

4) Number of Accidents in the last 4 years:

# of Points?

5) Total Fines received in the last 4 years:

6) Please detail ALL Violation (tickets) in the Last 4 years for primary driver. Please list the dates of the violations.

The following questions concern the type of auto coverage you are requesting. Please answer them as accurately as possible. Please Select From the Following:

1) Bodily Injury:

Property Damage Limit:

2) Uninsured Motorist Coverage:

3) Please indicate Which Features You Would Like:
 Medical Coverage Towing Coverage Rental Car Reimbursement Glass Coverage

The answer to these basic questions will help us process your information.

1) Best Time To Contact:    

2) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

    

1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                

9. Zip Code: