Contractor Insurance for New Mexico

Commercial Auto Insurance - Information Request Form

Company Info

Why so much information?
Contact Name Address
Company Name City
Company Type Zip Code
# of Owners, Members, or Officers Email
Phone

Underwriting Info

EIN# Currently Insured?
Type of Business - Please be specific and tell how vehicle(s) are used: Name of Carrier
How Long Insured?
Claims in the past 3 years:

Driver Information

Driver #1 (if more than 2 drivers, list in remarks)

Driver Name Date of Birth
License #
# of Accidents/5 Years # of Major Cites/5 Years (DUI, Reckless Driving)
Does Driver need SR-22 Filing? # of Minor Cites/5 Years (Speeding, red light)

Driver #2 (if more than 2 drivers, list in remarks)

Driver Name Date of Birth
License #
# of Accidents/5 Years # of Major Cites/5 Years (DUI, Reckless Driving)
Does Driver need SR-22 Filing? # of Minor Cites/5 Years (Speeding, red light)

Commercial Vehicle Information

Vehicle #1 (if more than 2 vehicles, list in remarks)

Year of Vehicle Make & Model
Type (Pickup, Tow Truck, Bobtail, Etc.) Radius of Operation
Vehicle ID Estimated Current Value
Do you want comprehensive & collision on thie vehicle?

Vehicle #2 (if more than 2 vehicles, list in remarks)

Year of Vehicle Make & Model
Type (Pickup, Tow Truck, Bobtail, Etc.) Radius of Operation
Vehicle ID Estimated Current Value
Do you want comprehensive & collision on thie vehicle?
Remarks - List Extra Vehicles / Drivers