COMMERCIAL AUTOS INSURANCE APPLICATION

Personal Information
First Name
Last Name
Address
City
Zip
State
Lease or Purchase	Lease Purchase

Vehicle Information
Year
Make
Model
Mileage

Discounts on Vehicles
Alarm	Yes No
ABS	Yes No
Air Bag	Yes No

Have you had an accident prevention Course?	Yes No
Have you had an unfortunate situation made you filed with the state bankruptcy	Yes No
Number of Licensed operators in your household
How many years have you been licensed in NY other than NY

In Your Driving History You Had
Moving Violation	Yes No
Major violation	Yes No
Minor Violation	Yes No
Accident Violation	Yes No

In Your Driving History You Had
Moving Violation	Yes No
Major violation	Yes No
Minor Violation	Yes No
Accident Violation	Yes No

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Fill out the form again for your next vehicle after filling out his form.

ALL FORMS OF INSURANCE

The Bennett Brokerage Inc.

2290 Babylon Turnpike, Suite A

Merrick, NY 11566

PHONE: 516-223-4902

FAX: 516-223-5359

Commercial Auto Private Passenger Auto

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