Palm Beach Insurance Group, Inc. - Peace Of Mind. Palm Beach Style.

LET US QUOTE YOUR COMMERCIAL AUTO INSURANCE!

Please note that this form is a PRICE QUOTE REQUEST ONLY. Filling out and submitting this form DOES NOT bind coverage in any way. The only way coverage can be bound is when an agent of Palm Beach Insurance Group has issued the binder or policy and then notified you that it has been issued. IF YOU DO NOT AGREE WITH THIS DISCLAIMER, DO NOT CONTINUE!

By submitting this Quote Form, you confirm that you have read and agree to the above disclaimer.

INSURED INFORMATION

Business Name:*

Contact:*

Phone:*

Street Address:*

City:*

State:*

Zip:*

Email Address:*

Type of Business:

Prior Ins?:

Prior Company:

Expires:
mm/dd/yyyy

LIST ALL DRIVERS (Please call our office if you have more than 4 drivers to insure)
Name:*	SS#:*	DL# & State:*	DOB:*mm/dd/yyyy	Usage:*	Yrs Exp:*	Sites/ Day:*




OK to Run MVR's?:

ACCIDENTS/VIOLATIONS/CLAIMS IN LAST 3 YEARS
Operator?	Date mm/dd/yy	Description

VEHICLES TO BE COVERED (Please call our office if you have more than 4 vehicles to insure)
	Year:*	Make:*	Model:*	VIN#:	ABS?	Air Bags?	Alarm?	Cost New:*	Hired
Veh#1
Veh#2
Veh#3
Veh#4

COVERAGE LIMITS
	BI Liability*	PD Liability*	PIP Limit*	UM - Stacked/ Non-Stacked*	Medical
Veh#1
Veh#2
Veh#3
Veh#4
	Comp.Ded.	Coll.Ded.	Towing?*	Rental?*
Veh#1
Veh#2
Veh#3
Veh#4

Click Here to Clear This Form	Click Here to Email This Form to Us!

If you do not hear from us in a reasonable amount of time, it means we did NOT receive this request for a quote, so please call our office at (561) 624-0361.
Thank you for allowing us the opportunity to serve you!

To discuss your commercial automobile coverage needs, please contact Jon Kocha at:
(561) 624-0361 ext. 203
(561) 543-0364
(561) 644-3152 or email us at info@palmbeachinsgroup.com

Need Help?

Call 561.624.0361,
email us at: info@
palmbeachinsgroup.com,
or visit us at:
13700 U.S. Highway One,
Suite 102
Juno Beach, FL 33408

Tell A Friend!