Linares Ins - Auto - Property - Commercial - Life

Commercial Auto Quote Information Sheet

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Company Name:

Email:

Website:

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Address

Street Address:

City:

State:

Postal/Zip Code:

Home Number:

Cell Number:

Business Operations:

Business Entity:

Contact Name:

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Vehicle #1:

Make:

Year:

Model:

Vehicle Cost New:

VIN:

GROSS VEHICLE WEIGHT:

LICENCE #:

VEHICLE USAGE:

RADIUS:

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Vehicle #2:

Year

Make

Model

VIN

GROSS VEHICLE WEIGHT:

DRIVER NAME:

DOB: (e.g. Month, Date, Year)

LICENCE #:

VEHICLE USAGE:

RADIUS:

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Vehicle #3:

Year

Make

Model

Vehicle Cost New:

VIN

GROSS VEHICLE WEIGHT:

DRIVER NAME:

DOB: (e.g. Month, Date, Year)

LICENCE #:

VEHICLE USAGE:

RADIUS:

CURRENT INSURANCE COMPANY:

EXPIRATION DATE:

ANY CLAIMS IN THE PAST 3 YEARS

Yes

CARGO NEEDED $:

ANY STATE FILINGS REQUIRED:

Yes

LIMITS NEEDED:

LIABILITY:

UNINSURED MOTORIST:

COMPREHENSIVE:

COLLISION:

Quote Requested By :

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Disclamer: Quotes are only indications and good for 30 days. Actual "Premium" may differ upon submission and verification of information. If currently covered by insurance, a copy of the most recent policy will be extremely helpful. Quoted premium includes all applicable fees and administration chages.

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Linares Insurance Agency
23505 Crenshaw Blvd., Suite 225
Torrance, CA 90505
Tel: (310) 347-3700
Fax: (310) 856-4285

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Linares Insurance Agency23505 Crenshaw Blvd., Suite 225 Torrance, CA 90505Tel: (310) 347-3700Fax: (310) 856-4285

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Linares Insurance Agency
23505 Crenshaw Blvd., Suite 225
Torrance, CA 90505
Tel: (310) 347-3700
Fax: (310) 856-4285