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Insurance Masters
Insurance Agency
5180 Wilshire Blvd.
Los Angeles, CA 90036
Calif. Insurance
License #0696284

On-Line Commercial Vehicle Quote Form One Simple Form - takes only 2-3 Minutes! YOUR PERSONAL DATA:
Your Name:
Business Name:
Street Address:
City:
State:	MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again, to verify):
Phone:
Fax (optional):

Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)

Type of Business: (Please be specific, and tell how vehicles are used.)


DRIVER INFORMATION #1 (if more than two drivers, list in remarks)
Name:		Birthdate:
Sex:		# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or CALL US Toll Free at: 800 491-7283
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE #1 COVERAGES:
Limits of Liability:	$15/30 BI / 10 PD $25/50 BI / 15 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $250/500 BI / 100 PD $1 Million

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists?	Yes No

COMMERCIAL VEHICLE #2:
Year of vehicle:		Make & Model:
Type (truck, tow-truck, bobtail, etc.):		Length in Feet:
Radius of operation:		Value $:
List Special Equipment & Values (i.e., rack, tool box, etc.)
VEHICLE #2 COVERAGES:
Limits of Liability:	$15/30 BI / 10 PD $25/50 BI / 15 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $250/500 BI / 100 PD $1 Million

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists?	Yes No


Send my quotation via:	E-Mail Fax Regular Mail Call Me by Phone

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below 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.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!

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Thank you for Visiting the Web Site of Insurance Masters.net
Contact us via E-Mail at: insmastersLA@pacbell.net
5180 Wilshire Blvd. Los Angeles, CA 90036    |    Phone: 323-931-6968
Out of Area Toll Free Phone Number: 800-491-7283    |   Fax: 323-931-6628
Questions or site-related technical problems, contact: insmastersLA@pacbell.net
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