IMPORTANT NOTICE

1. This commercial vehicle insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if you do not live in Oregon or Washington.

2. This form can accept information for only one vehicle and only one driver. If you have multiple vehicles or drivers, it is best to call us and talk to one of our agents concerning your insurance information.

3. No insurance will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you complete and sign the insurance application and pay the initial premium.

4. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or toll-free 1-888-620-0230.

Commercial Auto Quote Request
  1. Date you want coverage to begin
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  2. Your First Name
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  3. Your Last Name
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  4. Phone Number
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  5. Email Address
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  6. Business Website, if any
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  7. Name of Business or DBA
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  8. Business Type
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  9. Street Address
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  10. City
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  11. State
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  12. ZipCode
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  13. Your Home Address, if different from business address
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  14. Your Date of Birth
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  15. Social Security Number
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  16. Business Description
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  17. What percentage of your business involves repossession work?
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  18. Is your business on-call 24/7?
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  19. Does your business have contracts with any organizations?
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  20. Year your business started
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  21. Vehicle Year
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  22. Vehicle Make
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  23. Vehicle Model
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  24. Vehicle Body Style
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  25. Vehicle ID Number
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  26. Business Use
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  27. Is the vehicle also used personally?
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  28. Garaging Zip Code
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  29. Daily Radius One Way
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  30. Current Vehicle Value
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  31. Permanent Attached Equipment?
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  32. Name Of Loss Payee
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  33. Driver's First Name
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  34. Middle Initial
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  35. Last Name
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  36. Date of Birth
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  37. Marital Status
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  38. Drivers License State
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  39. Drivers License Number
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  40. Do you have a commercial drivers license?
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  41. If 'Yes,' what year was it issued?
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  42. Do you need an SR-22?
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  43. Describe all accidents and violations in last 36 months. and dates they occurred
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  44. Are you currently insured?
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  45. Name of the insurance company
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  46. Policy Number
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  47. Current Effective Date
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  48. CurrentExpirationDate
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  49. Current Liability Limits
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  50. Have you had continuous coverage for at least one year?
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  51. Does your business have general liability coverage?
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  52. Are there any additional insureds?
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  53. Any waivers of subrogation?
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  54. Any state or federal filings required?
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  55. Does the applicant own any other commercial vehicles?
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  56. Does the applicant own any other personal vehicles?
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  57. Additional Information or Comments
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  58. Re-type the Security Field numbers in the box
  59. Security Field
    Security Field
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  60. To save a copy of this form, please Print before Submitting.
  61. Submit
      

 

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Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.