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  • List of Carriers/MGA's currently quoted with:*
  • Requested Effective Date:*
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    2 digit month, 2 digit day, 4 digit year
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  • Foreclosures, repossessions, judgments, liens or bankruptcy in past 5 years?*
  • Any foreign products sold or distributed?*
  • Any policy declined, cancelled or non-renewed?*
  • Formal safety program in place?*
  • Any known claims or losses?*
  • Written safety program in place?*
  • Vehicle Maintenance Program in place?*
  • Does Applicant obtain MVR’s for verification?*
  • DMV Filing Required?*
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  • Coverage Requested: Limits ($)*
  • Motor Truck Cargo*
  • Driver List:*
  • Vehicle List:*

  • *Complete all items in sections for which quote is requested.

    **Please provide loss run report for past five years. They will be required to bind unless this is a new venture or no prior insurance. (Loss Run Report Forms located on website)
     

    NOTE : Any quotation provided via this application is subject to the terms and conditions of the specified insurance company forms currently in use, including any amendatory endorsements and/or exclusions. THE QUOTATION MAY NOT CONFORM TO THE TERMS AND CONDITIONS REQUESTED. It is the responsibility of the retail insurance broker to review the terms of any quotation carefully with your Insured. Insurance Solutions Pacific Coast, Inc., disclaims any responsibility for any differences between the terms quoted and the terms originally requested.

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