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E-Mail:
vickie@contractors
1stinsurance.com

Toll Free Phone:
800-238-4654

Insurance License
Numbers:
 CALIFORNIA OE61983
TEXAS 1416119
ARIZONA 873215
COLORADO 277626
FLORIDA 141611
LOUISIANA 417236
NEVADA 634600

Contractors We Write:

• Framers
• Roofers
• HVAC
• Drywall
• Plasterers

• Masonry
• Concrete
• Sanitation
• Janitorial
• Plumbers

• Electricians
• Low Voltage
• Landscapers
• Grading
• Excavation

• Paving Contractors
• New Home Builders
• Artisan Contractors
• Tile Contractors
• Pool Contractors

• Welders
• Steel Contractors
• Sheet Metal
• Ornamental Metal
• Pipeline Contractors

• Floor Installers
• Cabinetmakers
• General Contractors
• Remodelers
• Home Builders

• Commercial Contractors
• Developers
• Tract Home Builders
• Condo Builders
• Many More!

Website Design by:
Insurance-Web-Sales © 2008

 
On-Line Commercial
Vehicle Quote Form
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL DATA:

Your Name:
Business Name:
Street Address:
City:
State:
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: 800-238-4654
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
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

 
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