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Online Commercial Vehicle Quote Form One Simple Form - takes only 2-3 Minutes! YOUR PERSONAL DATA:
Your Name:
Business Name:
Street Address:
City:
State:	MUST be Florida!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):

Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)

Type of Business: (Please be specific, and tell how vehicles are used.)


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:		Daily commute in ONE WAY miles:
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:		Daily commute in ONE WAY miles:
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: 800-269-8775
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:	$500,000 CSL $750,000 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 #2 COVERAGES:
Limits of Liability:	$500,000 CSL $750,000 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


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Questions? E-Mail Us At: len@iadvant.com. Or call us at: 800-269-8775
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