Application For Vehicle Insurance
If you have more than one site, call us or complete an application for each site....whatever works best for you.
Business Name
Mailing Address
City/ST/ZIP
Site Address
Your Name
Telephone Number
Fax Number
e-mail Address
Ownership
Year Business Began

Check the boxes that best describe your operations

 Day Care
Center

 Service
Agency

 Infant
Center

 Residential
Care
Head
Start

 Camps

 Enrichment
Center

 Computer
Lab
Grade
School

 Counseling
Center

 Club

 Teen
Center

Current Coverage Expires

Current Insurance Company

Are there drivers under 25 years of age
Are there drivers with less
than 3 years licensed driving
experience in California

Coverage
Liability

Uninsured
Motorist

UMPD
Medical
Payments

Comprehensive

Collision

Drivers
1 Birth

Date		 California

Drivers

License
2
3
4
5
6
7
V
e
h
i
c
l
e

1		 Manufacturer
Model Name
Model Year
Seating Capacity,
including driver
Is vehicle used to
bus people or students
Current Market Value
Equipped with wheel chair lift
Value of non-factory equipment
Normal Operating Area
Zip Code where Car stays at night
V
e
h
i
c
l
e

2		 Manufacturer
Model Name
Model Year
Seating Capacity,
including driver
Is vehicle used to
bus people or students
Current Market Value
Equipped with wheel chair lift
Value of non-factory equipment
Normal Operating Area
Zip Code where Car stays at night
V
e
h
i
c
l
e

3		 Manufacturer
Model Name
Model Year
Seating Capacity,
including driver
Is vehicle used to
bus people or students
Current Market Value
Equipped with wheel chair lift
Value of non-factory equipment
Normal Operating Area
Zip Code where Car stays at night

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