Name
Phone
6650 Reseda Blvd
Suite #108
Reseda, CA 91335
contact@gisinsure.com
Commercial Auto
First Name:
Last Name:
Business Name:
Type of Business:
# of Years in Business:
# of Years in Trucking/Driving:
Garaging Address:
Garaging City:
Garaging State:
Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Idaho
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Garaging Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?
Select...
Flyer or Postcard
Yellow Pages
Newspaper
Referred
AOL Search Engine
MSN Search Engine
Yahoo Search Engine
Google Search Engine
Overture/GoTo Search Engine
Alta Vista Search Engine
Lycos Search Engine
Infoseek Search Engine
Excite Search Engine
Mailing Address (Optional)
Mailing Address
If Different from Garaging:
Mailing City:
Mailing State:
Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Mailing Zip Code:
Driver Information
Driver One
Driver Two
Driver Three
Driver Four
First Name
Birthdate
Sex
...Select
Male
Female
...Select
Male
Female
...Select
Male
Female
...Select
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Yrs Licensed
State Licensed
Drivers License Type
Drivers License #
Social Security #
Vehicle Information
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Year
Make
Model
I.D. #
G.V.W.
Miles Driven
Each Year
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Avg. Radius Miles Driven
0-50
51-100
101-150
151-200
201-300
301-500
501-1000
Unlimited
0-50
51-100
101-150
151-200
201-300
301-500
501-1000
Unlimited
0-50
51-100
101-150
151-200
201-300
301-500
501-1000
Unlimited
0-50
51-100
101-150
151-200
201-300
301-500
501-1000
Unlimited
Ownership
...Select
Leased
Paid-Off
Financed
...Select
Leased
Paid-Off
Financed
...Select
Leased
Paid-Off
Financed
...Select
Leased
Paid-Off
Financed
Original Cost New
Current Value
Violation Information
Last 3 Yrs (Minors)
Last 5 Yrs (Majors)
Driver 1
Driver 2
Driver 3
Driver 4
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Non Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Coverage Information
Bodily Injury
Property Damage
Personal Liability
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
300,000 CSL
500,000 CSL
600,000 CSL
750,000 CSL
1,000,000 CSL
5,000
10,000
25,000
50,000
100,000
Uninsured Motorist
None
15,000/30,000
25,000/50,000
30,000/60,000
50,000/100,000
100,000/300,000
250,000/500,000
60,000 CSL
300,000 CSL
500,000 CSL
600,000 CSL
750,000 CSL
1,000,000 CSL
None
3,500
Deductible Waiver
Medical Payment:
None
1,000
2,000
2,500
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Deductible Information
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Comprehensive (Theft)
...Select
250
500
1,000
1,500
2,000
...Select
250
500
1,000
1,500
2,000
...Select
250
500
1,000
1,500
2,000
...Select
250
500
1,000
1,500
2,000
Collision
...Select
250
500
1,000
1,500
2,000
2,000
...Select
250
500
1,000
1,500
2,000
...Select
250
500
1,000
1,500
2,000
...Select
250
500
1,000
1,500
2,000
Miscellaneous Information
Prior Insurance Information
Current Year
2nd Year
3rd Year
Name of Company
Effective Date
Expiration Date
Premium Paid
Claims/Losses in the last 3 yrs:
...Select
Yes
No
If Yes to above,
Please provide Details:
Any Filings Required:
...Select
Yes
No
CA Filing #:
ICC/FHWA Filing #:
USDOT Filing #:
MC #:
Current Insurance Company:
Expiration Date:
Current Premium $:
How Many STOPS a Day AVERAGE per Vehicle?
Type of Product/Cargo Hauled/Carried:
Value/Limits of Product/Cargo Hauled/Carried:
$
Deductible for Product/Cargo Hauled/Carried:
$
Questions or Comments
to help the Agent:
