Florida Commercial Auto Insurance Quote

Contact Information

First name ✶

Last name ✶

Phone ✶

Email ✶

Title ✶

Date of birth ✶

Co-Owner

Name

Relationship

Date of birth

Business Information

Business Name ✶

FEIN

Years in Business ✶

Legal Entity ✶

Annual revenue ✶

Website ✶

Industry ✶

Description of operations ✶

Location

Street address ✶

City ✶

State ✶

ZIP ✶

Business Vehicles & Drivers

# of drivers ✶

# of vehicles ✶

Drivers

Driver name ✶

Date of birth ✶

Driver's License Number

Accidents, tickets and/or claims in the past 5 years? ✶

Yes

If yes, upload loss runs from the current insurance company for the last 5 years

Or email to membersinsurancecentercommercial [at] floridamic [dot] org

Vehicles

Year ✶

Make ✶

Model ✶

VIN ✶

Insurance History

Claims History

Accidents, Tickets and/or Claims? ✶

Yes

Claims information ✶

Current Insurance

Do you have a General Liability Policy currently in force? ✶

Yes

Insurance company ✶

Policy expiration ✶

Current premium ✶

Current Policy

You can also email your policy to mail your current policy to us at miccommercial [at] floridamic [dot] org

Desired Insurance Coverage

Additional lines of business

Buildings

Business Personal Property

Time Element / Loss of Income / Extra Expenses

General Liability

Umbrella / Excess Liability / Higher Limits

Employment Practices Liabilities

Directors / Officers Liability (Private or Non-Proft)

Professional / Errors and Omissions Liability

Commercial Auto

Workers’ Compensation

Crime

Cyber Liability

Equipment/ Inland Marine

Personal Lines/Residential

Performance / Payment / Other Bonding Needs

Garage Policy (Dealer & Non-Dealer)

Comments or questions

I understand that coverage cannot be bound or altered until the information has been confirmed by one of our representatives by phone or email. ✶

Subject

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COMMERCIAL AUTO INSURANCE QUOTE

Contact Information

Business Information

Business Vehicles & Drivers

Insurance History

Desired Insurance Coverage