Commercial Lines – Owned Business AutoEmet Digital2019-01-02T12:05:35-08:00 Get started by filling out this form and someone from our team will contact you shortly! Commercial - Owned Business Auto Customer InformationWhat is the name that the insurance will be under?* If you do not have a company, the name on the policy needs to match the name you are using for your vendors, permit offices or any other contracts that you have.What type of entity is this insurance going to be for?*Choose OneCorporationIndividual or DBAL.L.C.Non-ProfitPartnershipPlease provide a precise description of your business operations:*Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this where your vehicles are garaged?* Yes No Please provide your garaging address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person* First Last Email* Enter Email Confirm Email Phone*What date do you want this policy to start?* MM slash DD slash YYYY Prior Insurance / ClaimsAny prior insurance?* Yes No Please provide the policy numbers, premiums and expiration dates of your prior insurance:*Any prior claims?* Yes No Please provide the dates, amounts of the claim(s) and descriptions of what happened:*Do you have loss runs that you can provide?* Yes No Please upload your loss runs here.*Accepted file types: pdf, jpg, gif, png, xls, xlxs, doc, docx, , Max. file size: 50 MB. Driver InformationHow many drivers are there for your vehicle(s)?* 1 2 3 4 Driver 1 InformationName First Last Date of birth MM slash DD slash YYYY Driver's License Number Driver 2 InformationName First Last Date of birth MM slash DD slash YYYY Driver's License Number Driver 3 InformationName First Last Date of birth MM slash DD slash YYYY Driver's License Number Driver 4 InformationName First Last Date of birth MM slash DD slash YYYY Driver's License Number PhoneThis field is for validation purposes and should be left unchanged.
