NON-TRUCKING
				AUTO LIABILITY
Insureds Name:
Street Address:
State:		Select Maryland Pennsylvania Delaware New Jersey Virginia Washington DC				Zip:
County:
Commodity Hauled:
Years in Business:
Radius of Operation:			Select Less than 50 Miles 50 to 100 Miles 100 to 300 Miles Over 300 Miles
Largest City Entered:
Does Insured haul for
more than one concern:			Select Yes No
Please list names of
concerns hauled for:
								Percent
	Name			Commodity				of Time
Vehicle Schedule:
							Stated
Year	Make		Type		GVW		Amount
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
Driver Schedule:
			Date of	Years
Name			Birth	Exp.	Violations
Liability Limits:			Select 100,000 300,000 500,000 1,000,000
UM / UIM:			Select 100,000 300,000 500,000 1,000,000
Does Insured want
physical damage:			Select Coverage Wanted No Coverage Wanted
	Spec. Perils Deductible:			Select 250 500 1,000 2,500
	Comp. Deductible:			Select 250 500 1,000 2,500
	Collision Deductible:			Select 250 500 1,000 2,500
Any Claims past 3 Years:				Yes No
If claims, please provide details:
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact:
Contact E-Mail Address:
Thank you for completing this E-Submit Quick Quote Questionaire. Please
click on the "Submit" button below to send the submission to our office. You
can also start the quoting process over again by pressing the "Reset" button.