Insurance Quick Quote Indication

Commercial Auto, Business Auto, and Hired Auto Insurance

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Your Name:
Business Name:
Address:
Address continued:
City:	State: Zip Code:
Email Address:
Business Phone:	Home Phone:
Mobile Phone:	Fax:

Contractor’s License Type:

Vehicle #1

Make of vehicle:
Model of vehicle:
Year of vehicle:	Vehicle Value (when new): $
Another vehicle?	Yes No

Vehicle #2

Make of vehicle:
Model of vehicle:
Year of vehicle:	Vehicle Value (when new): $
Another vehicle?	Yes No

Vehicle #3

Make of vehicle:
Model of vehicle:
Year of vehicle:	Vehicle Value (when new): $
Another vehicle?	Yes No

Vehicle #4

Make of vehicle:
Model of vehicle:
Year of vehicle:	Vehicle Value (when new): $
Another vehicle?	Yes No

Vehicle #5

Make of vehicle:
Model of vehicle:
Year of vehicle:	Vehicle Value (when new): $

Desired Terms for Quote

Liability Limit:	$100,000 $300,000 $2,000,000 $5,000,000
Comp Collision Deductible:	$250 $500 $1,000
Is Debris Hauled for Others:	Yes No
Trailer Hitch:	Yes No
Use of vehicles:
Annual Payment Preference:
Current Policy Expiration:
Current Policy Carrier:

Licensed Agent / Broker Information

Are you a licensed insurance agent or broker?	Yes No

	If YES, please complete this section.
Producer (Insurance Agent/Broker):
Insurance Agency Name:
Email Address:

Prior to binding any coverage with AMIS, we must have a signed Broker Agreement, a copy of your Broker/Insurance License, and a copy of the declaration page of your E & O Insurance policy. Click here for more information.
Did you previously provide your agency information to AMIS?	Yes No

	If NO, please complete this section.
Agency License Number:
Street Address:
City:	State: Zip Code:
Contact Person Phone:	- -
Name of E&O Insurance Company:
E&O Policy Number:
E&O Policy Expiration Date:	/ / (M / D / YYYY)

Comments, Priority, Terms of Use

Comments or Additional Info:

Please Prioritize Your Request:	Hurry! I need it ASAP! Please quote prior to my renewal No hurry, just checking

By submitting this quick quote application, you declare that the information you are providing is accurate and complete to the best of your knowledge and belief.

AMIS/Alliance Marketing & Insurance Services does not warrant or guarantee suitability or adequacy of coverage in meeting any generic, specific or contractual requirements of any insurance company, state, county, corporation, public entity, or public party that you may provide services to during the policy period, including any written or oral request forwarded to AMIS or its staff. You assume the risk of obtaining suitable or adequate coverage to meet any generic, specific or contractual requirements of your client or company. The information contained herein is provided with the understanding the AMIS is not engaged in rendering legal services, including legal opinions or advice, or professional risk management consulting. If legal services or professional services are required, you will need to seek the advice of legal counsel.

You agree:	Yes NoNOTE: This constitutes a digital signature.

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NOTE: An application or information form is not an insurance policy and does not bind any coverage. All applications must be underwritten and a quotation will be issued subject to underwriting guidelines. The quotation does not bind coverage.