Commercial Insurance Underwriter

CIU

Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

 

AUTO QUICK INDICATION QUESTIONNAIRE (LESS THAN 5 UNITS)

 

AGENCY NAME:

Contact:

Email:

Phone Number:

Fax:

 

APPLICANT INFORMATION:

Effective Date:

Applicant/Business Name:

Address:
  Street                                             City                       State                       County                          Zip

 

Description of Operations:   Individual:
Commodities Hauled:   Corporation:
Number of Years In Business:   Partnership:
Number of Years Experience:   Other:

 

Current Insurance Carrier Name:
Expiring Premium: $

Expiration Date:
5 Year Loss History (include Driver Name, Date and Amount Paid and Details for each Loss):

 

GENERAL INFORMATION:

Does Applicant Haul For Hire or Owned Goods (describe):
Major Cities & States Entered:
State Filings Needed: State ID #;
Federal Filings Needed: Federal ID #:
MCS 90 Needed: US DOT #:
Does Applicant Broker Loads:

If Yes, please provide details:

 

DRIVER INFORMATION:
NAME DRIVING RECORD DATE OF BIRTH YEARS EXPERIENCE HIRE DATE

 

MAKE / MODEL / USE / BODY TYPE YEAR VALUE GVW OR # PASS. GARAGING CITY & ZIP RADIUS

 

COVERAGE AND LIMITS:

(Check one) Primary Liability:

 

or Non-Trucking Liability:

If so, Permanently Leased to:
 
Auto Liability Limit:  $
Medical Payments Limit:  $

UM Limit:

  $
PIP Limit:  $ UIM Limit:  $
 
PHYSICAL DAMAGE COVERAGE / DEDUCT:  

CARGO COVERAGE:
Specified Causes of Loss:  $   Limit:  $
Comprehensive:  $   Deductible:  $
Collision:  $   Commodities:  

 

Additional Information/Coverage Request/Remarks/Any Special Equipment attached:

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.