Commercial Auto Liability & Physical Damage

We accept requests for quotes only from licensed agents or brokers. However if you are interested in an Insurance Quote please contact us (E-MAIL, PHONE, FAX) and we will refer you to a licensed broker near you.
- Agency Name
- Address
- Contact Name
- Agency Account Nbr.
If you do not have an account with FTP complete and forward our
New Brokerage Account Questionaire

Select State in which the Risk is located:

- Applicant's Name
- Address
- Garage if Different

Named insured is: - Indiv. - Corp. - Partnership - Other

- Nature of Business Operation
-Years in business
Coverage Cancelled or Non-Renewed in past 3 Years

Loss History-Past 3 Years


Covered Auto Symbols:
1. Any auto
2. All owned autos
3. Owned private passenger autos
4. Owned autos other than private passenger
5. All owned autos which require no-fault coverage
6. Owned autos subject to compulsory U.M. law
7. Autos specified on schedule
8. Non-owned autos

Liability Symbol 1 7 Limits -
PIP Symbol 5 7 Basic PIP Pedestrian
Additional PIP Symbol 2 7 Option # -
Medical Payments Symbol 2 7 Limits -
Uninsured Mototrists Symbol 2 7 Limits -
Hired Auto Symbol 1 8 Cost of Hire -
Comprehensive Symbol 2 7 Deductible
Collision Symbol 2 7 Deductible
Towing & Labor (PPT only) Limits -
Rental Reimbursement (PPT only) Amt. per day # of Days -
Non-Owned Auto Symbol 1 9 # of Employees -


VEHICLE DESCRIPTION
No.# Year Make/Model/Body Type Vin # Use GVW Class Cost New Radius Loss Payee


DRIVER INFORMATION

Name Date of Birth License Number State of License


INFORMATION ON FAMILY RELATED DRIVERS (for individual and partnerships) Non-Business Drivers

Name Date of Birth License Number


OTHER NON-Business

Private Passenger How Many Present Carrier
Other Vehicles How Many Present Carrier
Type

GARAGE SITUATION

- Garaged - Fenced Open Lot - Open Lot lighted
- Open Lot - Vehicle W/Alarm - Garage Alarm - Perimeter Alarm


Enter any Additional Information Here:


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