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CGA Business Auto Insurance Quote Request
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

Application Information Section
Name:
Business Name:
Type of Business:
Garaging Address:
Garaging City:
Garaging State:
Garaging Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

Mailing Information
Mailing Address
If Different from Garaging:
Mailing City:
Mailing State :
Mailing Zip Code:

Vehicle Information Section
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Year
Make
Model
I.D. #
G.V.W.
Miles Driven
Each Year
Radius Driven
(Average)
Ownership

Driver Information Section
  Driver One Driver Two Driver Three Driver Four
First Name
Birthdate
Sex
Marital Status
Yrs Licensed
State Licensed
License Type

Driver Violation Section
Last 3 Yrs (Minors)
Last 5 Yrs (Majors) 		Driver 1 Driver 2 Driver 3 Driver 4
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.
Accidents - Non Chargeable
Accidents - Chargeable
Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.

Coverage Information
Bodily Injury Property Damage
Personal Liability
Uninsured Motorist
Medical Payment:

Deductibles
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comprehensive (Theft)
Collision

Loss Information
Current Insurance Company:
Expiration Date:
Current Premium $:
Questions or Comments
to help the Producer:

 
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