INFORMATION AGENCY’S PHONE NUMBER: PRODUCER NAME: AGENCY NAME: 636-695-5868 Paul’s Cell D Paul Bell Provider Alliance Insurance / MTM PROPOSED EFFECTIVE DATE NAMED INSURED: INSURED FEIN or SSN: (mm/dd/yyyy): CITY: ST: ZIP CODE: ADDRESS: BUSINESS WEBSITE ADDRESS, IF APPLICABLE: BUSINESS PHONE: DESCRIPTION OF OPERATION: CITIES VEHICLES REGULARLY OPERATE: RADIUS IN MILES: YEARS IN BUSINESS: PRIOR INSURANCE: YES NO EXPIRING CARRIER: COVERAGE LIMITS LIABILITY: UM: UIM: MED: PHYSICAL DAMAGE DEDUCTIBLE: PIP: GL: Please Note: Physical Damage is NOT available for salvaged vehicles. VEHICLE INFORMATION LIFT OR YEAR MAKE VIN $ VALUE RAMP? 1 Yes No 2 Yes No 3 Yes No 4 Yes No DO YOU ACCEPT FARES UTILIZING ANY TYPE OF PASSENGER-HAILING MOBILE APPLICATION? (e.g. Uber, Hailo) Yes No DRIVER INFORMATION (Attach MVRs if Possible) # of YEARS DOB TRAFFIC FIRST NAME LAST NAME m/d/yyyy DRIVER’S LICENSE # 1 2 3 4 LOSS INFORMATION (Or Attach Loss Runs) CARRIER POLICY YEAR LOSSES WRITTEN PREMIUM 1 2 3 COMPLETED BY:
INFORMATION PRODUCER NAME: D Paul Bell AGENCY NAME: Provider Alliance Insurance / MTM AGENCY’S PHONE NUMBER: 636-695-5868 Paul’s Cell NAMED INSURED: INSURED FEIN or SSN: PROPOSED EFFECTIVE DATE (mm/dd/yyyy): ADDRESS: CITY: ST: ZIP CODE: BUSINESS WEBSITE ADDRESS, IF APPLICABLE: BUSINESS PHONE: DESCRIPTION OF OPERATION: CITIES VEHICLES REGULARLY OPERATE: RADIUS IN MILES: YEARS IN BUSINESS: PRIOR INSURANCE: YES NO EXPIRING CARRIER: COVERAGE LIMITS LIABILITY: UM: UIM: MED: PIP: GL: PHYSICAL DAMAGE DEDUCTIBLE: Please Note: Physical Damage is NOT available for salvaged vehicles. VEHICLE INFORMATION YEAR MAKE VIN $ VALUE LIFT OR RAMP? 1 Yes No 2 Yes No 3 Yes No 4 Yes No DO YOU ACCEPT FARES UTILIZING ANY TYPE OF PASSENGER-HAILING MOBILE APPLICATION? (e.g. Uber, Hailo) Yes No DRIVER INFORMATION (Attach MVRs if Possible) FIRST NAME LAST NAME DOB m/d/yyyy DRIVER’S LICENSE # YEARS # of TRAFFIC 1 2 3 4 LOSS INFORMATION (Or Attach Loss Runs) CARRIER POLICY YEAR LOSSES WRITTEN PREMIUM 1 2 3 COMPLETED BY:
MTM-Quick-Quote-2017-1-4-Vehicle-Fleet.docx