JM DOHERTY INSURANCE

1.

Insured Name:

Phone Number:

E-mail:

2.

Business Name:

Business Website:

3.

Address:

City:

State:

Zip:

4.

Garaging Address of Vehicle (if different from above):

Address:

City:

State:

Zip:

5.

Tax ID Number:

6.

Effective Dates: to

7.

Desired/Renewal Premium: (Don’t Know )

8.

Current Insurer:

9.

Years in Business:

10.

Legal Entity (LLC? Corp? Partnership?):

11.

Nature of Business/Description of Operations:

12.

How is Vehicle Used:

13.

Liability Limits Desired:

Gross Vehicle Weight:

14.

Physical Dam Deductibles Desired:

Radius of Operation:

Cost Vehicle New:

15.

Vehicle Information:

Vehicle #1	Year	Make	Model
Vehicle #1
Vehicle #2	Year	Make	Model
Vehicle #2
Vehicle #3	Year	Make	Model
Vehicle #3
Vehicle #4	Year	Make	Model
Vehicle #4

16.

Driver Information:

Driver #1 Name	License No.	DOB

Driver #2 Name	License No.	DOB

Driver #3 Name	License No.	DOB

Driver #4 Name	License No.	DOB

17.

Coverage Needed:

Additional PIP Comprehensive

Medical Payments Collision

Towing/Labor Hired/Non-Owned Auto Rental

18.

Please list all accidents past 3 years:

19.

Please list all moving violations last 3 years:

20.

Have you been canceled for non-payment of premium within the last 3 years?:
Yes No

How did you here about us?

REQUIRED. By checking this box, I understand that the information above is to garner an indication only. Coverage can not be bound without additional information, including a signed application. All indications are pending favorable loss history for prior 3 years and favorable MVRs.

Commercial Auto