Minnesota Trusted Choice Insurance Professionals!

Commercial Auto Insurance Request Form

Bob Meyer and his Staff provide Auto, Home, Life, Health, & Business Insurance for Lakeville, Farmington, Eagan, Apple Valley, Burnsville, and the Greater Minneapolis/St. Paul Area of Minnesota.   Representing over 20 quality insurers for the best value and choice in insurance protection. 

Representing Minnesota's Leading Trusted Choice Insurers!

 Items marked with an asterisk (*) are required questions

Commercial Auto Insurance Quote Request

Business Name:
Your Name:*
Street Address:
City
State:
Zip Code:
Email Address:*
Daytime Phone:*
Fax: (Optional)
Currently Insured? Yes, Continuous for 3 years or longer
Yes, Continuous for less than 3 yrs.
No
Type of Business: (Explain, be specific)
Driver #1 Name:
Driver #1 Birthdate:
Driver #1 Sex: Male
Female
Driver #1 MN License #:
Driver #1: Number & Type of Accidents W/I last 5 years.
Driver #1: Number & Type of Violations W/I Last 5 Years.
Driver #1: (Which Vehicle does this Individual Drive?)
Vehicle #1: Model Year
Vehicle #1: Make & Model
Veh #1 Type of Vehicle (ie. tow truck, box)
Veh # 1 Length in Feet:
Veh #1: Gross Vehicle Weight
Veh #1 Cost New:
Veh # 1: Radius of Operation - Miles
Veh # 1: Current Value of Vehicle:
Veh # 1 Special Equipment & Values:
Vehicle ID # (VIN)
Veh # 1 COVERAGES - Limits of Liability $100,000/$300,000/$50,000
$300,000 CSL
$250,000/$500,000/$100,000
$500,000 CSL
$1,000,000 CSL
Veh # 1 PHYSICAL DAMAGE - Collison No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Veh # 1 PHYSICAL DAMAGE - Comprehensive No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Veh # 1 Uninsured & Underinsured Motorists Same as Liability
Decline, as vehicle is in storage
Veh # 1 Is Primary Driver Covered by Workers Compensation? Yes
No
Unsure
Veh # 1, Personal Injury Protection - No Fault Standard 20,000 Medical/20,000 Non-Med
No Coverage Desired, vehicle in storage
Additional Coverage Desired
Driver # 2 Name
Driver # 2 Birthdate:
Driver # 2 Sex: Male
Female
Driver # 2 MN Drivers License #:
Driver # 2 Accidents & Violations Last 5 years: (Give Details)
Driver # 2 Which Vehicle Does Individual Normally Drive?
Driver # 2 Comments or Remarks:
Vehicle # 2 Model Year:
Vehicle # 2 Make & Model
Vehicle # 2 - Type, Tow Truck, Box Truck:
Vehicle # 2 Length in Feet:
Vehicle # 2 Gross Vehicle Weight:
Vehicle # 2 Cost New
Vehicle # 2 Radius of Operation: (Miles)
Vehicle # 2, Special Equipment & Values:
Vehicle # 2, Vehicle ID #:
Vehicle # 2, COVERAGES - Limits of Liability: No Coverage
Same as Vehicle # 1
Vehicle # 2, Collision No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Vehicle # 2, Comprehensive No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Vehicle # 2, Uninsured & Underinsureds Motorists No Coverage Desired, vehicle in storage
Same Coverage as Vehicle # 1
Not Sure - Tell me more about this coverage.
Vehicle # 2, Personal Injury Protection - No Fault Standard 20,000 Medical/20,000 Non-Med
No Coverage Desired, vehicle in storage
Additional Coverage Desired
I hereby give my permission to run required reports, including Insurance Scoring:* Yes, Required to obtain a quote. See paragraph & link below.
No, No quote will be provided.
Vehicle # 2, Is Primary Driver Covered by Workers Compensation? Yes
No
Unsure
Additional Comments, Additional Vehicles or Drivers, Etc:

You should know:  Agents and Insurance Companies must check your driving record, history of losses, and run your insurance score to obtain your auto insurance quote.  Insurance scores are unique for each company with some carriers giving discounts of up to 50% for those with exceptional credit.  So what is insurance scoring?   Learn More! 

By submitting this form, your are giving your permission.

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote results only to you. We will not give your data to any other person or group for sales, marketing, or for any other purpose. By requesting a quote you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Bob Meyer of Miller-Hartwig Insurance.  Your Trusted Choice Insurance Agent.

2008 PLINS