COMMERCIAL AUTO QUICK QUOTE

5252 Westchester St., Ste 260, Houston, TX 77005 • 281-501-8331
service@archerinsgroup.com • www.archerinsgroup.com • Se habla español

Commercial Auto Quick Quote

Request a commercial auto quotation by completing this form. To serve you best, we ask to act as your exclusive broker. Return by email to service@archerinsgroup.com.

Copy of current policy, insurance requirements, additional insureds list, lienholders list, and 5-year loss runs needed to quote.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Business Information

How Soon Do You Need Quotes? Due Date *

Desired Effective Date *

Legal Business Name *

DBA / Trade Name (if any)

Mailing Address *

City *

State *

ZIP *

Business Phone

Website

Social Media Handles

Business Owner Name *

Cell Phone

Email *

Primary Contact Name

Cell Phone

Title

Entity Type

Other Entity Type

FEIN or SSN (optional)

Year Business Started

NAICS / SIC Code

Owner Years in Industry

Gross Sales – Last 12 Mo $

Projected Sales – Next 12 Mo $

Prior Year Annual Payroll $

Est. Annual Payroll (current yr) $

Total # Employees

Current Annual Premium – all lines $

Describe Business Operations & Use of Vehicles

Current Insurance & Filings

Current Auto Carrier

Annual Premium $

Expiration Date

Federal / State Filings?

USDOT MC SR22 None

Other Filing Type & #

USDOT #

MC #

FMCSA/ICC Docket #

Auto Coverage Requested

Liability

UM / UIM

Medical Payments

PIP (if available)

Phys Dam Deductible

Hired / Non-Owned Auto

Cargo Limit

Cargo Deductible $

Vehicle Use & Operations

Garaging Address (if different from mailing)

Cities/Areas of Operation

Radius

Vehicles owned but not listed below?

# Power Units

# Trailers

Haul hazardous materials?

Interstate or Intrastate?

Vehicles used for livery / passengers (shuttle, rideshare)?

Equipment attached? Value $

Vehicles used for delivery or hauling goods for others?

Vehicle List Complete or attach your vehicle schedule

Unit 1

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Unit 2

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Unit 3

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Unit 4

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Unit 5

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Unit 6

Unit # (ID)

Year

Make

Model

VIN

Value $

Lienholder

Driver List Complete or attach your driver list + MVRs

Driver 1

Driver Name

Date of Birth

License #

State

Years Driving

CDL (Y/N)

Driver 2

Driver Name

Date of Birth

License #

State

Years Driving

CDL (Y/N)

Driver 3

Driver Name

Date of Birth

License #

State

Years Driving

CDL (Y/N)

Driver 4

Driver Name

Date of Birth

License #

State

Years Driving

CDL (Y/N)

Driver 5

Driver Name

Date of Birth

License #

State

Years Driving

CDL (Y/N)

Loss History

Any auto losses / claims in the past 5 years?

If yes, explain below

Authorization & Return

Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to market my account and act as my exclusive broker for this submission. I understand duplicate submissions by other agents can cause carriers to block our access and delay or jeopardize the best available pricing.

Applicant Signature (type full name) *

Date *

Print Name & Title

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

Our dedicated commercial risk advisor will review your submission and reach out with competitive quotes from top carriers. We partner with you to find the coverage that fits your fleet and business needs.