Dominique Adams Agency - Request Quote Form

Contact Info

Name:

Email:

example@example.com

Phone:

Type of Coverage Request

What coverages are you needing (Select all that apply):

Business Information

Legal Business Name:

DBA:

Entity Type:

Describe Entity Type:

Contact Person:

Phone Number:

Phone Type:

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Describe Business Activity:

Location Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Location:

Is the mailing address “same” as location address?

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:

example@example.com

Website:

Describe Other Coverage Needed:

Commercial Auto

List Vehicle / Trailer

Number of Vehicles / Trailers:

Vehicle / Trailer

Drivers:

Number of active drivers:

Driver:

Furthest Distance Traveled in One Direction:

Does insured currently have auto coverage

Current BI/PD Limits:

Current Policy Expiration Date:

Current Insurance Provider:

Optional Coverages:

Bodily Injury / Property Damage Limits:

Deductible:

USDOT #:

MC #:

Do any listed vehicles or load require a hazardous material placard?

What type of hitch is connected to vehicle?

Are state or federal filings required?

Motor Cargo Coverage:

Hired Auto Liability:

How much did the customer spend in renting, hiring, or borrowing vehicles last year?

Non-Owned Auto Liability:

One average, how many times per week are non-owned vehicles used in the business?

Equipment Coverage

Number of Units?

Listed Equipment: