CGA Business Auto Insurance Quote Request
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
Submitting Information
Business Name:
Contact Name:
Street Address:
City:
State:
ZIP:
County:
Email:
Business Phone:
Fax:
Application Information Section
Name:
Business Name:
Type of Business:
Garaging Address:
Garaging City:
Garaging State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Garaging Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Mailing Information
Mailing Address
If Different from Garaging:
Mailing City:
Mailing State :
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Mailing Zip Code:
Vehicle Information Section
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Year
Make
Model
I.D. #
G.V.W.
Miles Driven
Each Year
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Radius Driven
(Average)
0-25 Miles
26-50 Miles
51-100 Miles
101-150 Miles
151-200 Miles
201-250 Miles
251-300 Miles
301 + Miles
0-25 Miles
26-50 Miles
51-100 Miles
101-150 Miles
151-200 Miles
201-250 Miles
251-300 Miles
301 + Miles
0-25 Miles
26-50 Miles
51-100 Miles
101-150 Miles
151-200 Miles
201-250 Miles
251-300 Miles
301 + Miles
0-25 Miles
26-50 Miles
51-100 Miles
101-150 Miles
151-200 Miles
201-250 Miles
251-300 Miles
301 + Miles
Ownership
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Driver Information Section
Driver One
Driver Two
Driver Three
Driver Four
First Name
Birthdate
Sex
Male
Female
Male
Female
Male
Female
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Yrs Licensed
State Licensed
License Type
Driver Violation Section
Last 3 Yrs (Minors)
Last 5 Yrs (Majors)
Driver 1
Driver 2
Driver 3
Driver 4
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Non Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Coverage Information
Bodily Injury
Property Damage
Personal Liability
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
5,000
10,000
25,000
50,000
100,000
Uninsured Motorist
None
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
None
3,500
Deductible Waiver
Medical Payment:
None
1,000
2,000
2,500
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Deductibles
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Comprehensive (Theft)
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
Collision
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
250
500
1,000
1,500
2,000
Loss
Information
Current Insurance Company:
Expiration Date:
Current Premium $:
Questions or Comments
to help the Producer:
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