Coverage Information
Liability Amount (csl):	-Select- $300,000 $350,000 $500,000 $600,000 $1,000,000
Uninsured Motorist - Bodily Injury (csl):	-Select- $25,000 $50,000 $60,000 $100,000 $250,000 $350,000 $500,000 $1,000,000
Uninsured Motorist - Property Damage:	Yes   No
Medical:	-Select- None $500 $1,000 $2,000 $5,000
Hired Auto:	Yes   No
Non-Owned Auto:	Yes   No
Comprehensive Deductible:	Yes   No
Collision Deductible:	Yes   No

Vehicle Information
You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles
AUTO #1	Year	Make	Model	VIN #
Gross Vehicle Weight		Cost New	Radius (in miles, one way)	Vehicle Use
lbs.		$
What commodity(s) do they haul?:

 

AUTO #2	Year	Make	Model	VIN #
Gross Vehicle Weight		Cost New	Radius (in miles, one way)	Vehicle Use
lbs.		$
What commodity(s) do they haul?:

 

AUTO #3	Year	Make	Model	VIN #
Gross Vehicle Weight		Cost New	Radius (in miles, one way)	Vehicle Use
lbs.		$
What commodity(s) do they haul?:

 

AUTO #4	Year	Make	Model	VIN #
Gross Vehicle Weight		Cost New	Radius (in miles, one way)	Vehicle Use
lbs.		$
What commodity(s) do they haul?:

 

AUTO #5	Year	Make	Model	VIN #
Gross Vehicle Weight		Cost New	Radius (in miles, one way)	Vehicle Use
lbs.		$
What commodity(s) do they haul?:

 

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