Commercial Auto Insurance

13437 VENTURA BLVD., SUITE 205,
SHERMAN OAKS, CA 91423, USA.
Phone (818) 906-1454 Fax (818) 906-2682

Please complete the following general questionnaire. Our professional, courteous staff will contact you regarding your quote. Or call us at 1 (800) 779-PARS

General Information

Insured's Name
Phone Number
Fax Number
Email Address
Insured is
Business Name
Street Address

City

Zip Code

Gross receipts/last year
Estimated next year

Nature of Applicant's Business

Driver (1)
First name
Last name

Date of Birth

Number of years CA License

Number of years (Other state and International License)

Number of Accidents (if any)

At Fault Not At Fault

Number of Citations (if any)

Number of years commercial driving

Driver (2)
First name
Last name

Date of Birth

Number of years CA License

Number of years (Other state and International License)

Number of Accidents (if any)

At Fault Not At Fault

Number of Citations (if any)

Number of years commercial driving

Driver (3)
First name
Last name

Date of Birth

Number of years CA License

Number of years (Other state and International License)

Number of Accidents (if any)

At Fault Not At Fault

Number of Citations (if any)

Number of years commercial driving

Commercial Vehicle (1)

Year

Manufacturer

This is a

Current Actual Cash Value

Commercial Vehicle (2)

Year

Manufacturer

This is a

Current Actual Cash Value

Prior Insurance Company

Policy number

Cancelled or Non-renewed

Reason

Desired Coverages
Liability Coverage

Comp & Collision
Vehicle (1)
Comp Ded	Collision Ded
Vehicle (2)
Comp Ded	Collision Ded

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How did you hear about us

You can e-mail this form to us by pressing the submit button above. To fax the information, please print this form and complete the required information and fax to (818) 906-2682.

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