Hurst Weis Insurance & Investment Services

Business Auto Insurance Form

Business Name:
First Name:
Last Name:
Email:
Social Security Number
Street:
City:
State:
Zip:
Telephone Number
Please list all drivers
Name		Date of Birth	Drivers License Number








Vehicle #1 Description
Year	Make	Model	Vin Number
Vehicle Usage
Number of Miles One way to work.
Will the Vehicle be used for a business?		(Yes or No)
If yes please Describe

Vehicle #2 Description
Year	Make	Model	Vin Number
Vehicle Usage
Number of Miles One way to work.
Will the Vehicle be used for a business?		(Yes or No)
If yes please Describe

Vehicle #3 Description
Year	Make	Model	Vin Number
Vehicle Usage
Number of Miles One way to work.
Will the Vehicle be used for a business?		(Yes or No)
If yes please Describe

Vehicle #4 Description
Year	Make	Model	Vin Number
Vehicle Usage
Number of Miles One way to work.
Will the Vehicle be used for a business?		(Yes or No)
If yes please Describe
Are you currently insured?
If so, What is the name of the carrier?
Please list any accidents or tickets in the last 3 years.
Any major violations or suspensions in the last 5 years?
Additional Comments:		"Please understand that there is no coverage bound until you receive confirmation in writing from Hurst-Weiss Insurance."