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    • Questions?
    E-Mail us at:
     brian@cameron-group.com

    "Remember...All Our Policies Come With an Agent!"

    		 
    On-Line Commercial
    Vehicle Quote Form
    One Simple Form - takes only 2-3 Minutes!
    YOUR PERSONAL DATA:

    Your Name:
    Business Name:
    Street Address:
    City:
    State:
    Zip/Postal:
    E-Mail (REQUIRED):
    Phone:
    Fax (optional):
     
    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If no, type NONE)
     
    Type of Business:
    (Please be specific, and
    tell how vehicles are used.)

     
    DRIVER INFORMATION #1
    (if more than two drivers,
    list in remarks)
    Name: Birthdate:
    Sex: # Years U.S.
     Auto License:
    Number & Type of
    Accidents within
    last 3 years:    		 Number & Type of
    MINOR Cites within
    last 3 years:
    Number & Type of
    MAJOR Cites within
    last 3 years:    		 Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
    Remarks?
     
    DRIVER INFORMATION #2 (if none, leave blank)
    Name: Birthdate:
    Sex: # Years U.S.
     Auto License:
    Number & Type of
    Accidents within
    last 3 years:    		 Number & Type of
    MINOR Cites within
    last 3 years:
    Number & Type of
    MAJOR Cites within
    last 3 years:    		 Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
    Remarks?

    COMMERCIAL VEHICLE #1:
    If more than 2 vehicles, list in remarks
    or call us at: 845-627-2130
    Year of vehicle: Make & Model:
    Type (truck, tow-truck, bobtail, etc.): Length in Feet:
    Gross Vehicle Weight: Cost
    New: $
    Radius of operation: Value $:
    List Special Equipment & Values
    (i.e., rack, tool box, etc.)

    VEHICLE ID#
    (highly suggested for accurate rating)

    VEHICLE #1 COVERAGES:
    Limits of
    Liability:    		 $50/100,000 BI / $25,000 PD
    $100/300,000 BI / $50,000 PD
    $250/500,000 BI / $100,000 PD
     
    Comprehensive
    & Collision:    		 NO Coverage $250 Deductible
    $500 Deductible $1000 Deductible
     
    Do you want
    Medical Coverage?    		 Yes No   Uninsured
      Motorists?    		 Yes No
     
    COMMERCIAL VEHICLE #2:
    Year of vehicle: Make & Model:
    Type (truck, tow-truck, bobtail, etc.): Length in Feet:
    Gross Vehicle Weight: Cost
    New: $
    Radius of operation: Value $:
    List Special Equipment & Values
    (i.e., rack, tool box, etc.)

    VEHICLE ID#
    (highly suggested for accurate rating)

    VEHICLE #2 COVERAGES:
    Limits of
    Liability:    		 $50/100,000 BI / $25,000 PD
    $100/300,000 BI / $50,000 PD
    $250/500,000 BI / $100,000 PD
     
    Comprehensive
    & Collision:    		 NO Coverage $250 Deductible
    $500 Deductible $1000 Deductible
     
    Do you want
    Medical Coverage?    		 Yes No   Uninsured
      Motorists?    		 Yes No
     
    Send my quotation via: E-Mail Fax
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    Questions? Email Us At: brian@cameron-group.com - The Cameron Group, Inc. - 55 Old Turnpike Rd, Suite 602 - Nanuet, NY 10954
    Phone: 845-627-2130 - Fax: 845-627-2749 - Office Map/Directions - Terms of Use/Privacy Notice - Site Last Updated: January 2006.
    Please report site-related technical problems to: brian@cameron-group.com    © 2006 Insurance-Web-Sales
     
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