PENNSYLVANIA RUSH QUOTE - Commercial Auto
1 & 2 Unit Risks
P. O. Box 9004, Long Beach, NY 11561-9004
TEL (516) 431- 6200  ·  FAX  (516) 431-0488 ·  www.dcwhiteagency.com


Producer: Phone:
Contact: Email: Proposed Eff. Date :

INSURED
Name:
Street Address : City: State: Zip:
Garage Address (if different): City: State: Zip:
Email: Phone:

OPERATIONS  Check one:  Business Auto  Motor Carrier (Trucker)

Description of Operations:

Check one: Motor Carrier     Dump & Transit Mix     Time Sensitive     Food Delivery     Contractor
Other (Specify):
Business Start Year:
Do you transport any hazardous materials? No     Yes   (specify):


SCHEDULE OF AUTOS TO BE USED (All units you own or leased to you must be scheduled & insured if filings apply)
No. Year Make/Model Vehicle
Identification No. 		Gross Vehicle Weight Original Cost New Maximum Radius Leased Vehicle
1.
 Yes 
No   
2.
 Yes 
No   

DRIVER INFORMATION
No. Driver Date of Birth License No. State Driver History Past 3 Years
# Violations # Suspensions # Accidents
1.
2.
3.

COVERAGE

Liability

 Physical Damage
Deductibles
Vehicle 1
Vehicle 2
Automobile Liability Comprehensive
Non Stacked Uninsured Motorists $ Collision
Non Stacked Underinsured Motorists $ On Hook (Tow Truck Only)
First Party Benefits BASIC
Are Filings Required?  No     Yes
DOT #: MC #:
Current Carrier:
Has an insurance company cancelled or non-renewed your policy in the last 3 years?  No     Yes

TERMS & CONDITIONS: Assumes no losses. For applicants with losses, please submit the application to dcwapplications@lancer-ins.com.

NOTE: The RUSH QUOTE form does not replace a completed and signed application, which may be required to bind coverage.  Any misstatement of rating information, misrepresentation or omission of material facts will be cause for account re-rating or possible withdrawal of quote.