(432) 620-0825 Midland, TX

Charlie Harris Insurance Agency, Inc.

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Commercial Auto Quote Form

General Information

Name of Business *

Contact Name *

Street Address *

City *

State *

ZIP *

Phone *

Email

Best time to call AM PM

Current Insurance Company (not agency)

Company Name

Policy Exp. Date

Current Premium

Vehicle Information (include all cars you or your business owns or leases)

Vehicle #1

Year

Make

Model

Sub Model

Body Type

Vehicle ID# (VIN)

If vehicle is kept at an address other than that listed above, please indicate:

Location City:

State:

Zip:

Full Coverage:
Yes No

Seasonal Use:
Yes No

Used from:

Used to:

Season Used:

Vehicle Used for:

Vehicle #2

Year

Make

Model

Sub Model

Body Type

Vehicle ID# (VIN)

If vehicle is kept at an address other than that listed above, please indicate:

Location City:

State:

Zip:

Full Coverage:
Yes No

Seasonal Use:
Yes No

Used from:

Used to:

Season Used:

Vehicle Used for:

Vehicle #3

Year

Make

Model

Sub Model

Body Type

Vehicle ID# (VIN)

If vehicle is kept at an address other than that listed above, please indicate:

Location City:

State:

Zip:

Full Coverage:
Yes No

Seasonal Use:
Yes No

Used from:

Used to:

Season Used:

Vehicle Used for:

Vehicle #4

Year

Make

Model

Sub Model

Body Type

Vehicle ID# (VIN)

If vehicle is kept at an address other than that listed above, please indicate:

Location City:

State:

Zip:

Full Coverage:
Yes No

Seasonal Use:
Yes No

Used from:

Used to:

Season Used:

Vehicle Used for:

Driver Information (including all licensed drivers in your Business)

Driver License Number

State

Driver #1

Driver's Name

Date of birth

Male/Female (M / F)
M F

Occupation

# of Yrs. Licensed

Married/Single (M / S)
M S

Driver #2

Driver's Name

Date of birth

Male/Female (M / F)
M F

Occupation

# of Yrs. Licensed

Married/Single (M / S)
M S

Driver #3

Driver's Name

Date of birth

Male/Female (M / F)
M F

Occupation

# of Yrs. Licensed

Married/Single (M / S)
M S

Driver #4

Driver's Name

Date of birth

Male/Female (M / F)
M F

Occupation

# of Yrs. Licensed

Married/Single (M / S)
M S

Driver #5

Driver's Name

Date of birth

Male/Female (M / F)
M F

Occupation

# of Yrs. Licensed

Married/Single (M / S)
M S

Liability

Class of Business

Retail

Wholesale

Retail or Wholesale

Service

Truckers

Food Concessions

Limits Requested

$1,000,000

Describe any claims you had in the past 3 years

Additional Comments

Please give any additional comments about the coverage you desire

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message

Ready for the next step? Call us at (432) 620-0825 or Request a Quote

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Charlie Harris Insurance Agency, Inc. | 10 Desta Drive, Suite 600E | Midland, TX 79705 | (432) 620-0825

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