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On-Line Commercial
Vehicle Quote Form
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL DATA:

Your Name:
Business Name:
Street Address:
City:
State: (Must be Texas)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
 
Type of Business:
(Please be specific, and
tell how vehicles are used.)

 
DRIVER INFORMATION #1
(if more than two drivers,
list in remarks)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Number & Type of
Accidents within
last 3 years:		 Number & Type of
MINOR violations within
last 3 years:
Number & Type of
MAJOR violations within
last 3 years:		 Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?
 
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Number & Type of
Accidents within
last 3 years:		 Number & Type of
MINOR violations within
last 3 years:
Number & Type of
MAJOR violations within
last 3 years:		 Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?

COMMERCIAL VEHICLE #1:
If more than 2 vehicles, list in remarks
or call us at: 1-956-661-8338
Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): Length in Feet:
Gross Vehicle Weight: Cost
New: $
Radius of operation: Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)

VEHICLE ID#
(highly suggested for accurate rating)

VEHICLE #1 COVERAGES:
Limits of
Liability:		 $500,000 CSL
$750,000 CSL
$1 Million CSL
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists?		 Yes No
 
COMMERCIAL VEHICLE #2:
Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): Length in Feet:
Gross Vehicle Weight: Cost
New: $
Radius of operation: Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)

VEHICLE ID#
(highly suggested for accurate rating)

VEHICLE #2 COVERAGES:
Limits of
Liability:		 $500,000 CSL
$750,000 CSL
$1 Million CSL
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists?		 Yes No
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!

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Jerry Molina Insurance Agency . 3313 N Ware Road, Suite 1 . McAllen TX 78501
Toll Free Phone: 1-888-668-8889 . Phone: 1-956-661-8338 . Fax: 1-956-661-0110
Our Normal Office Hours are: 9:00 to 5:00, Weekdays | View Our Privacy Notice
E-Mail us at: quotes@jerrymolina.com | Website Design © 2006, Insurance Web Sales