On-Line Tow Truck
Insurance Quote Form
YOUR PERSONAL DATA:
    Your Name:
    Business Name:
    Street Address:
    City:
    *State:
    Zip/Postal:
    E-Mail (REQUIRED):
    Confirm E-Mail:
    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 violations
    within last 3 years:
    Number & Type of
    MAJOR violations
    within last 3 years:		     Daily commute
    in ONE WAY miles:
    Does Driver need
    a 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 violations
    within last 3 years:
    Number & Type of
    MAJOR violations
    within last 3 years:		     Daily commute
    in ONE WAY miles:
    Does Driver need
    a SR22 FILING?		 Yes No     Comments or
    Remarks?
 
COMMERCIAL VEHICLE #1:
If more than 2 vehicles, list in remarks or call us at 660-397-2251
    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:		      $500,000 CSL
     $750,000 CSL
     $1 Million CSL
 
    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:		      $500,000 CSL
     $750,000 CSL
     $1 Million CSL
 
    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
     Regular Mail
     Call Me by Phone
 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!

*Hawkins Insurance Group is licensed to sell in more than 20 states. If you are contacting us from a state in which we are not licensed, we will contact you to inform you that we cannot provide you with a quote.
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P.O. Box 810, 4065 Highway 54, Suite One, Osage Beach, MO 65065

Phone 888.635.4668 or 573.348.1731 - Fax 573.348.5630

Copyright ©2010 Hawkins Insurance Group, Inc. All rights reserved.

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