Khalsa Insurance Agency
 
California License # 0F89805
 
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COMMERCIAL Auto Insurance Quote Form...
 
Full Name:
Address:
City:
State
ZIP:
Phone:
Work Phone Home Phone
   
E-Mail Address:
Present Auto Insurance Company:
Type of Business:
   
  Drivers Info.
   
  Driver 1
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
# Years U.S.  Auto License:
# Accidents & Type in 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:
Driver Currently Insured:
Social Security No.:
License No.:
Does Driver need an SR22 FILING?
 
  Driver 2
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
# Years U.S.  Auto License:
# Accidents & Type in 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:
Driver Currently Insured:
Social Security No.:
License No.:
Does Driver need an SR22 FILING?
 
  Driver 3
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
# Years U.S.  Auto License:
# Accidents & Type in 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:
Driver Currently Insured:
Social Security No.:
License No.:
Does Driver need an SR22 FILING?
   
  Commercial Vehicles Info.
   
  Vehicle 1
   
Type of Vehicle:
Year of Vehicle:
Make & Model:
Length in Feet:
Gross Vehicle Weight:
Radius of operation:
Value $:
List Special Equipment & Values:
(rack, tool box, etc.)
 
  Vehicle 2
   
Type of Vehicle:
Year of Vehicle:
Make & Model:
Length in Feet:
Gross Vehicle Weight:
Radius of operation:
Value $:
List Special Equipment & Values:
(rack, tool box, etc.)
 
  Vehicle 3
   
Type of Vehicle:
Year of Vehicle:
Make & Model:
Length in Feet:
Gross Vehicle Weight:
Radius of operation:
Value $:
List Special Equipment & Values:
(rack, tool box, etc.)
   
  Coverage's Info.
   
  Vehicle 1 Vehicle 2 Vehicle 3
       
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
$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
$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
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
       
Do you want Medical Coverage?
Uninsured Motorists?
 
 
 
 
 
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    Legal Information   |   Khalsa Insurance Agency Inc. 2020