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 Pennsylvania) Zip/Postal: E-Mail (REQUIRED): E-Mail (Again, for Accuracy): 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 violations within last 3 years: Number & Type of MAJOR violations 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 violations within last 3 years: Number & Type of MAJOR violations 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 at: 1-877-728-5539 Year of vehicle: Make & Model: Type (truck, tow-truck, bobtail, etc.): Length in Feet: Gross Vehicle Weight: Cost New: $ Radius of operation: Value $: List Special Equipment & Values (i.e., rack, tool box, etc.) VEHICLE ID# (highly suggested for accurate rating) VEHICLE #1 COVERAGES: Limits of Liability: $500,000 CSL $750,000 CSL $1 Million CSL   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: Gross Vehicle Weight: Cost New: $ Radius of operation: Value $: List Special Equipment & Values (i.e., rack, tool box, etc.) VEHICLE ID# (highly suggested for accurate rating) VEHICLE INFORMATION FOR UNITS #3-5: (If none, Leave Blank) VEHICLE #3 (List Year, Make, Model & Value) VEHICLE #4 (List Year, Make, Model & Value) VEHICLE #5 (List Year, Make, Model & Value) VEHICLE #2 - #5 COVERAGES: Limits of Liability: $500,000 CSL $750,000 CSL $1 Million CSL   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! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!	Pennsylvania Personal and Commercial Auto Insurance Discounts! Let us shop your Pennsylvania Auto Insurance for you. Ask about our 8% PAID-IN-FULL Auto Insurance Discount! Great values on: • Good Drivers • Multi Car Accounts • Home & Auto Combo • Fleet Discounts Get a FAST Personal Auto Quote Get a FAST Business Auto Quote   Hi Value Homes and $$ Multi-Million Estate Packages! We have the perfect homeowners solution for your high valued home. Low rates and maximium discounts. Get a Quote Condo and Renters Insurance Programs for Pennsylvania Now Available! If you are in need of Condo Insurance, or Renters Insurance, we can place coverage FAST and inexpensively. We also specialize in Personal Umbrella Coverage! Protect the Assets You Have Worked For! Get an Umbrella Quote   Business Owner's Program We specialize in business policies for most Pennsylvania retail, wholesale, and offices. We shop several carriers for the broadest coverage at the lowest price! CLICK FOR QUOTE NOW!
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