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:
Minnesota Drivers License #:
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:
Minnesota Drivers License #:
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:
952-469-0425
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:
$300,000 CSL
$500,000 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:
$300,000 CSL
$500,000 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:
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Mail Call Me by Phone
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