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Commercial Auto Application

Company Name*
Years in Business
Applicants Name*
Street Address*
Suite #
County*
City*
State*
Zip*
Mailing Address
Suite #
County
City
State
Zip
Phone*
Mobile Phone
Work Phone
Fax
Email*
Website
Nature and Description of Business
Type of Business Entity:
Current Policy Expiration:
Vehicle Description / Use

Vehicle # 1
Year
Make Model Body type
VIN # / Registered State
Date Leased
Date Purchased
Cost New
Lean Holder
Annual Mileage
Cost New
City State and Zip Where Garaged

Vehicle # 2
Year
Make Model Body type
VIN # / Registered State
Date Leased
Date Purchased
Cost New
Lean Holder
Annual Mileage
Cost New
City State and Zip Where Garaged

Vehicle # 3
Year
Make Model Body type
VIN # / Registered State
Date Leased
Date Purchased
Cost New
Lean Holder
Annual Mileage
Cost New
City State and Zip Where Garaged

Vehicle # 4
Year
Make Model Body type
VIN # / Registered State
Date Leased
Date Purchased
Cost New
Lean Holder
Annual Mileage
Cost New
City State and Zip Where Garaged

Vehicle #5
Year
Make Model Body type
VIN # / Registered State
Date Leased
Date Purchased
Cost New
Lean Holder
Annual Mileage
Cost New
City State and Zip Where Garaged

Current Vehicle Coverage's and Premiums:
Liability Combined Single Limit
Bodily Injury Person
Property Damage
Medical Payments
Uninsured Motorist
Comprehensive Deductible
Collision Deductible
Waiver of Collision Deductible
Towing & Labor
Rental
Non-Truckers/ Hired Borrowed
Combined Additional Coverage Deductible
Trailer Interchange

Use:
Farm
Commercial
For Hire Trucking
Retail
Service

Drivers Information
Driver #1
Name as it appears on License
Sex
Marital status
Date of birth
Date Licensed
Drivers License #
State Licensed
Social Security #
Date Hired
Vehicle # Used
% Used

Driver #2
Name as it appears on License
Sex
Marital status
Date of birth
Date Licensed
Drivers License #
State Licensed
Social Security #
Date Hired
Vehicle # Used
% Used

Driver #3
Name as it appears on License
Sex
Marital status
Date of birth
Date Licensed
Drivers License #
State Licensed
Social Security #
Date Hired
Vehicle # Used
% Used

Driver #4
Name as it appears on License
Sex
Marital status
Date of birth
Date Licensed
Drivers License #
State Licensed
Social Security #
Date Hired
Vehicle # Used
% Used

Driver #5
Name as it appears on License
Sex
Marital status
Date of birth
Date Licensed
Drivers License #
State Licensed
Social Security #
Date Hired
Vehicle # Used
% Used

Additional Interest:
Vehicle # 1
Is there an additional Interest?
Are you the Owner?
Is there Lien holder?
Are you the Registrant?

Vehicle # 2
Is there an additional Interest?
Are you the Owner?
Is there Lien holder?
Are you the Registrant?

Vehicle # 3
Is there an additional Interest?
Are you the Owner?
Is there Lien holder?
Are you the Registrant?

Vehicle # 4
Is there an additional Interest?
Are you the Owner?
Is there Lien holder?
Are you the Registrant?

Vehicle # 5
Is there an additional Interest?
Are you the Owner?
Is there Lien holder?
Are you the Registrant?

Prior Coverage	Yes No
Carrier
# of Years with Carrier

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. YES I AGREE TO THE ABOVE STATEMENT, PLEASE PROCESS MY QUOTE. SUBMIT MY APPLICATION

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Allegheny Pacific Insurance Services, Inc.
State of California Department of Insurance License # 0F82733
Corporate Office: 18405 Park Point Ct., Hidden Valley Lake, CA 95467
Office hours: Mon – Fri from 9 am to 5 pm. Call Us 877-ALLPAC1 Fax Us 707-929-0047
Please be aware that coverage cannot be bound, canceled or altered by sending a message via this Web site.
Contact your local Allegheny Pacific Insurance Services office for assistance with changes to your policy.
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