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Auto Services - Cal-Regent Insurance

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Auto Services - Cal-Regent Insurance Powered By Docstoc
					                                                                                                  California Quick Quote
                                                                                                       For Auto Services
                                                                                                            One Location
 Broker:          ____________________________________ Contact: ____________________________________________
 Phone Number: ____________________________________ Email:                   ____________________________________________
 Insured Name: ____________________________________ DBA:                     ____________________________________________
 Address (Loc 1): ____________________________________ City:                ___________________ State: ____ Zip: __________
 Describe type of shop/service: _________________________________________________________ Years in business: _____
 Describe any specialization (in makes or types of vehicle), if any: ____________________________________________________
 What percentage of your sales or repair is from the following:
      Autos         %       Pick-Up Trucks          %      Motorhomes         %      Large Trucks           %       Motorcycles            %
 Is the lot fully chained or fenced? Yes      No
 Current Carrier: ____________________________________ Current Premium: $ ___________ How Many Years Insured _____
 Claims: None in last 12 months:           Or, if claims in last 12 months, then contact underwriter before submitting!
 Remarks:         _________________________________________________________________________________________

Personnel Rating Information: (State the actual number of people at this location – NOTE: Part time rated as one-half an employee)

 Active Owners or Officers or Partners (Total Number of People!)
 Mechanics and Others who work at this location                                                            Full Time               Part Time

Garage Coverages, Limits & Deductibles Requested:
                            $100,000
 Garage Liability Limits: $ ___________________ CSL                 Aggregate: 1X      2X        3X        Deductible: $1,000       $500
 Broadened Liability? Yes        No                                 Or, Personal Injury Coverage? Yes        No          (Not Both!!!)
 Damages to Rented Premises: $ ____________________
 GKLL: $ ___________________________               Legal Form       Direct Primary           With: Deductible $1,000            Or, $500
 Medical Pay: $1,000           $2,000         $5,000                Type: Premises           Auto           Combined Auto & Premises

Property Coverage, Limits & Deductibles Requested:
 Building Type: Frame          Joisted Masonry          Non-Combustible        Square Footage: _______ Year Building Built: ________
 Building: $ ____________          Contents: $ ____________         Earnings Loss: $ ____________          Outdoor Sign: $ ____________
 Deductible: $1,000           $500                                  Central Station Alarm: Yes        No          (No Alarm = No Theft)
 Optional Property Package: Yes                                     Loss to Customer’s Personal Property Endorsement: Yes



                                             Add SCHEDULED AUTO SUPPLEMENT if needed

                        NOTE: Must Provide Full Application To Bind Risk!!!! This is just to get a fast quote!


                        CAL-REGENT Insurance Services Corporation • PO Box 711868 • Santee, CA 92072
                               phone (619) 596-2770 • fax (619) 596-4049 • CA License: 0C64516
                                                                                                   California Quick Quote
                                                                                                             One Location
                                                                                                      Scheduled Vehicles
Please fully describe each vehicle and state all applicable coverages and limits requested.
 VEHICLE NO. 1
 Year ________         Make ______________             Model ______________              VIN ____________________________________
                                                                                         License No. ______________________________
 Radius ______         Cost New ___________                      Passenger Car
                                                       Body Type ________________________
 COVERAGES:           Liability      Comp          Collision        With:         $500        $1,000 Deductible
                  Med Pay:         $1,000          $2,000         $5,000                      UM BI:     $15/30,000     $60,000


 VEHICLE NO. 2
 Year ________         Make ______________             Model ______________              VIN ____________________________________
                                                                                         License No. ______________________________
 Radius ______         Cost New ___________                      Passenger Car
                                                       Body Type ________________________
 COVERAGES:           Liability      Comp          Collision        With:         $500        $1,000 Deductible
                  Med Pay:         $1,000          $2,000         $5,000                      UM BI:     $15/30,000     $60,000


 VEHICLE NO. 3
 Year ________         Make ______________             Model ______________              VIN ____________________________________
                                                                                         License No. ______________________________
 Radius ______         Cost New ___________                      Passenger Car
                                                       Body Type ________________________
 COVERAGES:           Liability      Comp          Collision        With:         $500        $1,000 Deductible
                  Med Pay:         $1,000          $2,000         $5,000                      UM BI:     $15/30,000     $60,000


 VEHICLE NO. 4
 Year ________         Make ______________             Model ______________              VIN ____________________________________
                                                                                         License No. ______________________________
 Radius ______         Cost New ___________                      Passenger Car
                                                       Body Type ________________________
 COVERAGES:           Liability      Comp          Collision        With:         $500        $1,000 Deductible
                  Med Pay:         $1,000          $2,000         $5,000                      UM BI:     $15/30,000     $60,000


 VEHICLE NO. 5
 Year ________         Make ______________             Model ______________              VIN ____________________________________
                                                                                         License No. ______________________________
 Radius ______         Cost New ___________                      Passenger Car
                                                       Body Type ________________________
 COVERAGES:           Liability      Comp          Collision        With:         $500        $1,000 Deductible
                  Med Pay:         $1,000          $2,000         $5,000                      UM BI:     $15/30,000     $60,000


                        CAL-REGENT Insurance Services Corporation • PO Box 711868 • Santee, CA 92072
                               phone (619) 596-2770 • fax (619) 596-4049 • CA License: 0C64516

				
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