Commercial Auto Insurance Renewal Questionnaire

Please review your renewal carefully!  The following questions are designed to assist both of us in this review.

( * indicates required field)

GENERAL INFORMATION:
*Company Name:
*Policy Number
*E-mail address:
Website Address:
*Phone Number:
*Contact Person:
*Fax Number:
   
Is the named insured and address listed on the policy correct? Yes No
If you are incorporated, is the policy written in the corporate name? Yes No
Are all of the vehicles listed on your policy titled to the name as seen on your policy? Yes No
Does your business own any vehicles other than those listed on your policy? Yes No
   
COVERAGE INFORMATION:
After reviewing ALL of your policy, do you have adequate coverage? Yes No

If you answered “no”, do you wish to increase or add any of the following:
  Increase Bodily Injury Liability
  Increase Property Damage Liability
  Increase Medical Expenses/Loss of Income
 
Do you lease any vehicles (on a long-term or short-term basis)? Yes No
Do you own any trailers exceeding 2000 lbs. GVW other than those listed on your policy? Yes No
Do you have any equipment permanently attached to an insured vehicle? Yes No
 
VEHICLE INFORMATION :
Do you own any vehicles other than those listed on your policy? Yes No
If you answered “yes”, please provide the following information:
 
New
Vehicle 1: 		Purchase Date: Mo.    Year Cost:
Make: Model:
Year: Length:
Vehicle Identification Number: GVW:
 
New
Vehicle 2: 		Purchase Date: Mo.    Year Cost:
Make: Model:
Year: Length:
Vehicle Identification Number: GVW:
 
Do you regularly operate outside a 50-mile radius of your home office or office building? Yes No
Have you added any new operations (such as hauling for hire, leasing equipment)? Yes No
 
Are there any other coverages you want to discuss: Yes No
Life
Health
Auto
Long-Term Care
Would you like to schedule an appointment with one of our agents? Yes No
 
Please download this Commercial Driver Questionnaire and have all drivers (including the owner) fill it out completely.  All newly hired drivers must also complete this Authorization To Obtain Motor Vehicle Record form as well.
Additional Coverages needed
and/or additional comments:

I understand that NO changes to my policy or coverage are bound by submitting this online Renewal Request.
This Change request will be considered bound ONLY upon confirmation from my LIA agent.

I have read and agree with the above.
(Box must be checked before request is sent)

NOTE: This is to become part of your permanent insurance record with Lewis Insurance Associates
and will be shared with the company you are insured with.


   

 

© Copyright 2006 Lewis Insurance Associates
All rights reserved
Website design by: G3 website design + graphics