Auto Insurance Questionnaire - Brochure

AUTO INSURANCE QUESTIONNAIREPlease return this form by fax, mail, or email.1. Company Name:2a. Mailing Address:2b. City, State, Zipcode:3. Registered Owner of Vehicle(s):4. Garaging Location(s):5. List all vehicles (If necessary, attach sheet by):Make Model Vehicle ID No.Year (yyyy)Car 1Car 2Car 3Car 4Car 57. Description of any special equipment attached / materials handled:Full Name Date of Birth (mm/dd/yyyy) Driver License No.8. List of drivers (attach separate sheet if necessary):12345I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service FirmsI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms10. Complete description of any claims over the past 5 years (include date of accident, amount of loss, etc. – please send separate sheet if necessary. Include insurer loss runs if available):11a. Limits of Liability desired:11b. Uninsured Motorist limit:11c. Medical Payments limit:11d. Physical Damage desired? Yes No11e. If yes, Comprehensive Deductible amount:12a. Current number of employees: 12b. Number of employees 12 months ago:13. Will applicant implement a policy to not allow any driver with over 3 points to drive? Yes No14. Does applicant or owner have a separate personal auto policy? Yes No15. Does applicant allow any personal use of auto(s)? Yes No9. Please identify your Auto insurer for the past 5 years and policy number.Expiration Date (mm/dd/yyyy) Insurer Policy #12345Signature over printed name of person completing the questionnaire:Phone Number (ex: 000-000-0000): E-mail:Date (mm/dd/yyyy):CA Lic# 0821383P.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms 2a Mailing Address: 2b City State Zipcode: 3 Registered Owner of Vehicles: 4 Garaging Locations: 5 List all vehicles If necessary attach sheet by: Year yyyyCar 1: MakeCar 1: ModelCar 1: Vehicle ID NoCar 1: Year yyyyCar 2: MakeCar 2: ModelCar 2: Vehicle ID NoCar 2: Year yyyyCar 3: MakeCar 3: ModelCar 3: Vehicle ID NoCar 3: Year yyyyCar 4: MakeCar 4: ModelCar 4: Vehicle ID NoCar 4: Year yyyyCar 5: MakeCar 5: ModelCar 5: Vehicle ID NoCar 5: 7 Description of any special equipment attached materials handled: 8 List of drivers attach separate sheet if necessary: Full Name1: Date of Birth mmddyyyy1: Driver License No1: Full Name2: Date of Birth mmddyyyy2: Driver License No2: Full Name3: Date of Birth mmddyyyy3: Driver License No3: Full Name4: Date of Birth mmddyyyy4: Driver License No4: Full Name5: Date of Birth mmddyyyy5: Driver License No5: Expiration Date mmddyyyy1: Insurer1: Policy 1: Expiration Date mmddyyyy2: Insurer2: Policy 2: Expiration Date mmddyyyy3: Insurer3: Policy 3: Expiration Date mmddyyyy4: Insurer4: Policy 4: Expiration Date mmddyyyy5: Insurer5: Policy 5: send separate sheet if necessary Include insurer loss runs if available: 11a Limits of Liability desired: 11b Uninsured Motorist limit: 11c Medical Payments limit: 11d Physical Damage desired: 11e If yes Comprehensive Deductible amount: 12a Current number of employees: 12b Number of employees 12 months ago: 13 Will applicant implement a policy to not allow any driver with over 3 points to drive: 14 Does applicant or owner have a separate personal auto policy: 15 Does applicant allow any personal use of autos: Phone Number ex 0000000000: Email: Date mmddyyyy: Clear Form: