PUBLIC AUTO
				LIABILITY &
				PHYSICAL DAMAGE
Insureds Name:
Street Address:
State:		Select Maryland Pennsylvania Delaware New Jersey Virginia Washington DC			Zip:
City:
Is this a New Venture:			Select Yes No
Years in this Business:
Radius of Operation:			Select Less than 50 Miles 50 to 100 Miles 100 to 300 Miles Over 300 Miles
Most Frequently Entered Cities:
Do you carry workers comp insurance:					Select Yes No
Description of business:
						Percent
Please break down activities by percentage:						of Time
Airport Bus or Van
Airport Parking / Rental Car Shuttle
Bingo / Casino Bus
Boy / Girl Scout Bus
Charter Bus
Church Bus
City Transit Bus
Courtesy Bus - Hotel, Medical, etc
Day Care / Day Nursery
Employee Transportation
Inter City Bus
Limo - Airport
Limo - Special Occasions
Limo - Corporate Transfer
Medical - Non Emergency
School Bus
Sightseeing Bus
Taxicab
Other - Please describe:
Other - Please describe:
Other - Please describe:
Vehicle Schedule:							Seating
					Vehicle ID		Capacity
Year	Make		Model		Number		inc Driver
Are any of the units stretched:				Select Yes No			Stretch Length:
Are all vehicles equipped with seatbelts:					Select Yes No
Are vehicles only operated on a pre-arranged basis:							Select Yes No
Hours of Operation:
Driver Schedule:
			Date of	Years
Name			Birth	Exp.	Violations
Name			License State		License Number			Hire Date
Liability Limits:			Select 100,000 300,000 500,000 1,000,000
UM / UIM:			Select 100,000 300,000 500,000 1,000,000
PIP / FPB Limits:
Are Filings Needed:			Select No Filings ICC Filing PUC Filing
ICC Docket Number:
PUC Docket Number:
Does Insured want
physical damage:			Select Coverage Wanted No Coverage Wanted
Year	Make		VIN		Stated Value
	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
Prior Carrier:
Prior Premium:
Any Claims past 3 Years:				Yes No
If claims, please provide details:
Is there any additional information you would like to tell us about this insured:
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.