Quick Quote | Eastern Atlantic Insurance Company

Commercial Auto Quick Quote Application

Step 1 of 2

After submitting the form, you will be contacted by one of our agents as soon as possible.
You only need to fill out fields marked with an asterisk (*).
1. First Name:*
2. Last Name:*
3. Phone:*
Email:*
4. MC#
DOT#:*
5. Garaging Street Address*
City*
State*
Zip*
6. Effective Date of Coverage:*
MM slash DD slash YYYY
7. Radius of Operations:
% 0 - 100 miles*
% 101 - 300 miles*
% 301 - 600 miles*
% 600 + miles*
8. Do you haul Hazmat ?*
Passengers ?*
9. Year, make, model of each power unit and trailer you own, long-term lease or rent:*
Please fill out as much info as you can.

Additional Information (NOT required, but this information will help us give you the most accurate quote)
1. Business Name:
2. Company Type
- Sole Proprietor?
- Corporation ?
- LLC ?
- Joint Venture ?
3. Additional insureds ?

Please list the names of additional insureds.
4. Special requests such as additional insureds, oversize/overweight permits:
5. Commodities Hauled (with % of each) ?
Commodities Hauled %

Please list commodities hauled with % of each.
6. Claims last three (3) years
List all claims you have had in the last three years. Provide as much detail as you can including amounts paid.
7. Accidents and violations each driver has had in the last three (3) years
Please Note:
If we provide a quote from the information obtained through this website, it will be for the purpose of providing you with a helpful indication of our basic terms and price. Limits of liability, additional coverage options and deductibles will be discussed with you by the agent responding to this inquiry. Any quote offered will be subject to satisfactory answers to additional questions asked by this agent during the underwriting process. Coverage cannot be bound from this website even if a quote is provided. Eastern Atlantic Insurance Company reserves its right to decline any request for a quote or withdraw any quote previously issued. If we issue a policy based on information you provided that proves to be fraudulent in nature Eastern Atlantic Insurance Company will respond accordingly subject to the laws governing fraud and / or misrepresentation in effect in the state in which your business is domiciled. BY SUBMITTING THIS REQUEST YOU AGREE TO THESE TERMS AND CONDITIONS.
Comments
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Commodities Hauled	%

Commercial Auto Quick Quote Application

Step 1 of 2

Please Note: