Peter Laczko Insurance - Commercial Auto Quote Form

Commercial Auto Quote

Date:*

Business name:*

Business Address:*

Best phone #:*

Best email address:*

Owner/s name:*

D.O.B.*

If you are a trucking company: Dot # *

EIN:*

Year business started:*

Do you have current commercial insurance?*

YesNo

Previous Insurance:*

if so, how long?*

Any claims:*

Descriptions of operations (what do you do daily):*

Gross sales (or projected):*

Do you need “General Liability” if so, $1m per occurrence/$1m aggregate or $2m occ/$2m agg.
Do you need commercial “Commercial auto”, if so:

Vehicle

Desired limits of liability:*

Do you need workers compensation*

YesNo

if so: Yearly Salary $*

# of employees:*

How did you hear about us:*

Any information that you would like to add: