COMMERCIAL AUTO QUESTIONNAIRE

Applicant Name:

Address:
City / State / ZIP
Telephone/FAX:
Email/Website:
Business Entity:  
Business Type:  
Location Address:
City / State / ZIP
Number of Private
 Passenger Vehicles
Number of 
Commercial Vehicles
Type of Vehicle Number of Drivers
Comprehensive Deductible Collision Deductible Garage Location
Daily Driving Radius Primary Use
Claims History (over the last 5 years)
Number of Claims Approximate Amount Paid Claim Details

To Submit Request:
-- Complete Form, Print then
 FAX to (415) 454-8311
 or



Please Note: Our Agency Will Contact You Within the Next Business Day After Submitting REQUEST


Full-Service Insurance Agency
817 Mission Avenue - San Rafael - California 94901
Tele. (415) 454-0100 - FAX (415) 454-8311 - Toll Free (888) 822-4INS(4467)
WWW.MichaelMillerInsurance.com
California Insurance License 0541868