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Company Information
Contact Name
Company
Email
Phone - -
Fax - -
Address
Address 2
City
County
Zip
Underwriting Information
Currently Insured? Yes No
Name of Carrier?
How Long Insured?


Type of Business
(Please be specific, and tell how vehicles are used.)
Driver Information
Driver 1 (if more than two drivers, list in remarks)
Driver Name
Gender Yes No
Number/Type
Accidents Last 3yrs
Number/Type
Minor Cites Last 3yrs
Does Driver Need
SR22 FILING? 		Yes No


Date of Birth
Number of Years U.S. Auto License
Number/Type
Major Cites Last 3yrs
Daily Commute
(ONE WAY Miles)
Comments


Driver 2 (if none, leave blank)
Driver Name
Gender Yes No
Number/Type
Accidents Last 3yrs
Number/Type
Minor Cites Last 3yrs
Does Driver Need
SR22 FILING? 		Yes No
Date of Birth
Number of Years U.S. Auto License
Number/Type
Major Cites Last 3yrs
Daily Commute
(ONE WAY Miles)
Comments
Commercial Vehicle Information
Vehicle 1 (if more than two vehicles, list in remarks or call us at 888-553-0021)
Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID#
(for accurate rating)


Make & Model:
Length in Feet
Cost New
Current Value


List Special Equipment & Values
Vehicle 1 Coverages
Limits of Liability $500,000 CSL $750,000 CSL
$1 Million CSL
Do you want Medical Coverage? Yes No


Comprehensive
& Collision 		NO Coverage $250 Deductible
$500 Deductible $1,000 Deductible
Uninsured Motorists? Yes No


Vehicle 2 (if more than two vehicles, list in remarks or call us at 888-553-0021)
Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID#
(for accurate rating)


Make & Model:
Length in Feet
Cost New
Current Value




List Special Equipment & Values
Vehicle 2 Coverages
Limits of Liability $500,000 CSL $750,000 CSL
$1 Million CSL
Do you want Medical Coverage? Yes No


Comprehensive
& Collision 		NO Coverage $250 Deductible
$500 Deductible $1,000 Deductible
Uninsured Motorists? Yes No


Comments/Remarks


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San Bernardino Contractors Insurance offered for virtually all CA contractors
San Bernardino County CA Daggett CA Lucerne Valley CA Rialto CA
  Devore CA Lytle Creek CA Rice CA
Adelanto CA Devore Heights CA Mentone CA Rimforest CA
Amboy CA Earp CA Montclair CA Running Springs CA
Angelus Oaks CA Fontana CA Morongo Valley CA San Antonio Heights CA
Apple Valley CA Forest Falls CA Mount Baldy Village CA San Bernardino CA
Baker CA Fort Irwin CA Mountain View Acres CA Searles Valley CA
Baldwin Lake CA Goffs CA Muscoy CA Skyforest CA
Barstow CA Grand Terrace CA Nebo Center CA Sugarloaf CA
Big Bear City CA Helendale CA Needles CA Trona CA
Big Bear Lake CA Hesperia CA Newberry Springs CA Twentynine Palms CA
Big River CA Highland CA Nipton CA Twentynine Palms Base CA
Bloomington CA Hinkley CA Oak Glen CA Twin Peaks CA
Bluewater CA Hodge CA Oak Hills CA Upland CA
Cadiz CA Joshua Tree CA Ontario CA Valley of Enchantment CA
Cedar Glen CA Kingston CA Oro Grande CA Victorville CA
Chino CA Kramer Junction CA Phelan CA Wonder Valley CA
Chino Hills CA Lake Arrowhead CA Pinon Hills CA Wrightwood CA
Colton CA Landers CA Rancho Cucamonga CA Yermo CA
Crafton CA Lenwood CA Red Mountain CA Yucaipa CA
Crestline CA Loma Linda CA Redlands CA Yucca Valley CA


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