Donnelly & Sproul, Inc. - Commercial Automobile Insurance Quote Form

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Commercial Automobile Insurance Quote Form

We would like to provide you with a free, no-obligation commercial automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Insured:
Address:
City:	State: Zip:
Business Phone:	Fax #:
Email Address:
Garaging Address (type "same" if same as above):
City:	State: Zip:

Coverage Information

Liability Amount (csl):

Uninsured Motorist - Bodily Injury (csl):

Uninsured Motorist - Property Damage: Yes No

Medical:

Hired Auto: Yes No

Non-Owned Auto: Yes No

Comprehensive Deductible: Yes No
If "Yes",

Collision Deductible: Yes No
If "Yes",

Vehicle Information

You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles

AUTO
#1 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#2 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#3 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#4 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

AUTO
#5 Year Make Model VIN #

Gross Vehicle Weight Cost New Radius
(in miles, one way) Vehicle Use

lbs. $

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

Loss Information

How many losses have there been in the last 3 years?
(If any, please explain below)

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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Donnelly & Sproul, Inc.

55 Harristown Rd.
Glen Rock, NJ 07452 Phone:
Fax: 201-493-9002
201-493-9004

Email: mail@donnellyandsproul.com

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

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