IA Near Me

Name	:	Victoria Adgett
License ID	:	3659421
Phone	:	(775) 800-9545
Email	:	[email protected]
Address	:	3115 Knight Road, Reno, Nevada, 89509

Applicant
Business
Drivers
Vehicles
Policy
Loss
Miscellaneous
Finish

Applicant

First Name *

Last Name *

Where should we send your quote?

Email *

Phone *

Please fill all the mandatory questions.

Business

Business Info

Business / Company Name *

Founding Date *

DBA (If Applicable)

FEIN # (If Applicable)

Business Address

Address *

City *

State *

Zip code *

Is the Mailing Address different from the Business Address? *

Yes

Mailing Address

Address *

City *

State *

Zip Code *

Organization Type *

Garage Address

Address *

City *

State *

Zip Code *

Is the Garage Mailing Address different from the Garage Address?

Yes

Garage Mailing Address

Address *

City *

State *

Zip Code *

Internal

Type of Operation

Which category best describes your business? *

Retail (selling goods/products)

Service (no product sales, providing services)

Contractor / Construction

Manufacturing / Processing

Wholesale / Distribution

Transportation / Trucking

Professional Services (office-based)

Hospitality (restaurant, hotel, etc.)

Agriculture / Farming

Other

Please specify type of operation *

Full-Time Employees

Part-Time Employees

Description of Business

Operations & Driving Exposure

Percentage of driving in urban vs. highway environments

Do drivers take vehicles home?

Yes

General Company / Fleet Safety Questions

Do you have a formal driver hiring and screening procedure in place?

Yes

Are Motor Vehicle Records (MVRs) obtained for all drivers prior to hire and reviewed at least annually?

Yes

Do you conduct background checks on all drivers?

Yes

Do you maintain a written fleet safety program?

Yes

Is there a designated safety manager or supervisor responsible for driver safety?

Yes

Do you provide ongoing driver safety training (e.g., defensive driving, accident prevention)?

Yes

Do you have a policy prohibiting distracted driving, including mobile phone use?

Yes

Are drivers subject to drug and alcohol testing (pre-employment and/or random)?

Yes

Do you use telematics or GPS tracking systems to monitor driving behavior?

Yes

Do you have a progressive disciplinary program for unsafe driving?

Yes

Do you provide incentives for safe driving performance?

Yes

Are speeding, harsh braking, and driving habits monitored?

Yes

Do you subcontract or use independent drivers?

Yes

Are certificates of insurance obtained?

Yes

Please fill all the mandatory questions.

Drivers

Driver 1

Can you tell us about the Driver?

Are you an owner? *

Yes

Full Name *

Date of Birth *

Marital Status *

Gender *

Male

Female

Non Binary

License Information

Driver's License Number *

License State

Age Licensed (Years)

Do you have any tickets?

Yes

Ticket 1

Ticket Information

Type of Ticket

Please specify Type of Ticket

Date of Ticket

Do you have any accidents?

Yes

Accident 1

Accident Information

Type of Accident

Please specify Type of Accident

Date of Accident

Driver Profile & Driving History

Does driver hold a valid Commercial Driver’s License (CDL)?

Yes

CDL Class

Number of years of experience operating commercial vehicles

Maximum Gross Vehicle Weight (GVW) operated

Does this driver have any accidents or violations in the past 3–5 years?

Yes

Please provide details

Does this driver completed any formal driver safety training programs?

Yes

Is this driver subject to hours-of-service (HOS) regulations?

Yes

Does the driver maintain driver logs (ELD or manual)?

Yes

Is the driver allowed to use the vehicle for personal use?

Yes

Please describe limitations

Home Address

Address *

City *

State *

Zip Code *

Please fill all the mandatory questions.

Vehicles

Vehicle 1

Vehicle Details

VIN Number

Vehicle’s purchased date

Year *

Make *

Model *

Body Style

Usage for the Vehicle

How is the Vehicle Used?

How is the vehicle used commercially?

Vehicle Individual Owned or Business Owned

Annual Miles

Radius Miles

Is Vehicle Furnished?

Yes

Rental for Transportation

Deductible

Comp. Deductible

Collision Deductible

Limit of Liability

Medical

Type of Vehicle

Any Filing Required?

Specify (Filling Required)

Specify type of vehicle

How is your vehicle primarily used?

Specify vehicle primarily used

Are any hazardous materials transported?

Yes

Is vehicle used for delivery, service, or transportation of people?

Yes

Vehicle Safety & Equipment

Does the vehicle have a rearview (backup) camera?

Yes

Is the vehicle equipped with a driver monitoring system (e.g., fatigue or distraction detection)?

Yes

Does the vehicle have GPS tracking or telematics installed?

Yes

Is vehicle equipped with collision avoidance systems (e.g., forward collision warning, automatic braking)?

Yes

Is there a regular maintenance and inspection program for this vehicle?

Yes

Are maintenance logs and records kept for this vehicle?

Yes

Is the vehicle subject to daily pre-trip and post-trip inspections?

Yes

Are vehicles garaged or stored in a secured location when not in use?

Yes

Are dash cameras (inward/outward facing) installed?

Yes

Please fill all the mandatory questions.

Policy

History

Any policy or coverage declined, canceled, or non-renewed during the last three years for any premises or operations?

Yes

Reason for Cancellation

Have you had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last five years?

Yes

Do you have other business ventures for which coverage is not requested?

Yes

Type of Business

Prior Carrier

Do you have a prior or current commercial Auto? *

Yes

Name of the Insurance Company *

Policy Expiration Date *

Have you had any losses or claims? *

Yes

Please fill all the mandatory questions.

Loss

loss 1

Loss/Claim Details

Type of Loss *

Bodily Injury/Property Damage

Uninsured Motorist

Comprehensive

Collisionr

Other

Please specify type of loss *

Date of Loss *

Amount of Loss

Description of Loss

Please fill all the mandatory questions.

Miscellaneous

Is this a Subsidiary?

Yes

Has other Subsidiaries?

Yes

Do you have a Business Owners Policy Coverage? *

Yes

Do you have a General Liability Coverage? *

Yes

Additional Policies

Are you interested in additional policies?

BOP

Commercial Umbrella

Cyber Liability

Directors & Officers Liability

Employee Benefits Liability

Employment Practice Liability (EPLI)

Professional Liability / E & O

Workers' Compensation

Umbrella Coverage

Umbrella Limit

Please fill all the mandatory questions.

Commercial Auto

Applicant

Where should we send your quote?

Business

Business Info

Business Address

Mailing Address

Garage Address

Garage Mailing Address

Internal

Type of Operation

Operations & Driving Exposure

General Company / Fleet Safety Questions

Drivers

Driver 1

Can you tell us about the Driver?

License Information

Ticket 1

Ticket Information

Accident 1

Accident Information

Driver Profile & Driving History

Home Address

Vehicles

Vehicle 1

Vehicle Details

Usage for the Vehicle

Deductible

Vehicle Safety & Equipment

Policy

History

Prior Carrier

Loss

loss 1

Loss/Claim Details

Miscellaneous

Additional Policies

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