Commerical Automobile
Insurance Request Form

To receive a quote, please fill out the form below.....

Company Name:

Contact Person:

Address:

City, State Zipcode:

Phone Number:

E-Mail Address:

GENERAL QUESTIONS
What does your business do....

Any personal use of vehicles?	Yes No
Are physical examinations and drug test required as part of your driver hiring procedures?	Yes No
Do you have a random drug testing program in effect?	Yes No
Do you have any drivers that have been granted physical defect waivers?	Yes No

Current Carrier Information and Expiration date of policy?
Insurance Company Name: Expiration date:

Coverage Information.....

Liability Limit per Accident

Un & Underinsured Motorist Limit

Pennsylvania First Party Benefits

Medical Expenses

Extraordinary Medical Expenses
(Extraordinary Medical Benefits covers medical expenses over 100,000)

Work Loss Benefits

Funeral Expenses

Accidental Death Benefits

OR

COMBINED BENEFITS
Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit)

Liability Limit per Accident
Un & Underinsured Motorist Limit
Pennsylvania First Party Benefits
Medical Expenses
Extraordinary Medical Expenses	(Extraordinary Medical Benefits covers medical expenses over 100,000)
Work Loss Benefits
Funeral Expenses
Accidental Death Benefits
OR
COMBINED BENEFITS Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit)

Vehicle Information

Vehicle # 1 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 2 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 3 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 4 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 5 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 6 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 7 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 8 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 9 USE:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
				$	$
	Radius:				Gross Vehicle Weight:

Vehicle # 10 USE:

Year Make & Model/# Passenger VIN # Current Value/Worth Cost New Comp
Ded Coll
Ded

$ $

Radius: Gross Vehicle Weight:

Year	Make & Model/# Passenger	VIN #	Current Value/Worth	Cost New	Comp Ded	Coll Ded
			$	$
	Radius:	Gross Vehicle Weight:

Driver Information

Driver Name Birth License# Years Licensed Sex

ACCIDENTS & VIOLATIONS
Does any driver have any accidents or violations? Yes No

If YES, Please list ALL accidents and violations within last 3 years......

DATE	DRIVER NAME	TYPE OF OCCURRENCE


You can also fax this completed form to 1-888-800-0034

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474          (FAX) 327-7911
Toll Free: 1-800-977-2999     Fax: 1-888-800-0034

Company Name:
Contact Person:
Address:
City, State Zipcode:
Phone Number:
E-Mail Address: