Fillable Public Quote Sheet Agency Information Insured Information Prior (Risk Placement Services, Inc.)

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Public Quote Sheet Agency Information Insured Information Prior (Risk Placement Services, Inc.)

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Public Quote Sheet
1 to 4 Power Units
Underwriter:
Date:
Agency Information
Agent Code:
Agent Name:
State:
Person to Contact:
Insured Information
Insured Name:
Mailing Address:
Garaging Address:
Filings (Please provide ID #s if applicable):
Years in Business:
Major Cities Driving Into or Through:
Description of Operations:
Prior Carrier Info for the past 3 years
Year
Company Name and Policy Number
Losses
(Y/N)
Details
Driver Involved
If no prior insurance in own name, provide 3 years of driver employment history:
Driver Information
Driver Name
Date of
Birth
License Number
State
Date Hired
# of Yrs
Experience
Last 3 Years Violations
# of
Accidents
Vehicle Information
Year
Make
Model
# Of
Passengers
Present
Value
Radius
Miles
Length of Stretch
Coverage & Limits: Limousines & Sedans:
Auto Liability Limits
What % of trips are to & from the airport?
UM
Are you registered or licensed as a:
Limousine
Taxi
UIM
What % of your trips are unscheduled?
Medical Payments
Do any vehicles have a fare box or meter?
Specified Perils
Deductible
Do you charge by the:
Hour
Trip
Miles
Comprehensive
Deductible
Do drivers wear formal chauffeur’s attire?
Collision
Deductible
Do you have corporate contracts? If yes, list who the clients are:
Hired Car
Non-Owned
Full Size Van Section (12-15 Passenger)
Are driver assistants on board the vans?
Do you have any cargo racks on your vehicles?
Do you tow trailers with your van?
Is seat belt usage mandatory for all drivers & passengers?
If the van is of a 15 passenger configuration, is the rear-most seat removed?
Have you trained your drivers specifically on how to safely operate the full size van? If yes, please describe.
What kind of growth and/or changes expected in the next 12 months?
Comments:
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Public Quote Sheet Agency Information Insured Information Prior (Risk Placement Services, Inc.)

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Completed 23 November 2020

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