Business Name:    
Premises Address:
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 
Federal Employer's ID #:
Description of Operations or SIC code:

Arizona Vehicle Information:
(if more than 3 commercial vehicles please provide best time to contact)

Vehicle     Year              Make              Model             Body Type

Additional Vehicle Information:

                Miles          Cost                                          Where              Lienholder
Vehicle   Driven         New            VIN#                    Garaged              Yes/No

Arizona Commercial Auto Insurance Coverage Information:

                      Liability                 Property                   Uninsured
Vehicle  Combined Limits          Damage               Combined Limits         Medical
     2             SAME                       SAME                       SAME                   SAME
     3             SAME                       SAME                       SAME                   SAME

                   Collision         Comprehensive
Vehicle    Deductible           Deductible

Arizona Driver Information:

                                  Drivers                          Date of                                              Drivers
Driver                       Name                               Birth                  Gender                 License #

Is each employee's driving record accident & violation free during the past 5 years?
     1         If No, how many accidents?    How many violations? 
     2         If No, how many accidents?    How many violations? 
     3         If No, how many accidents?    How many violations? 

Was any employee's driver's license suspended during the past 5 years?

Recent Insurance Information:

Current Insurance Company: 
Expiration Date: (mm/dd/yyyy)
Any losses past 3 years:
Description of losses, including amount paid on each accident:

Additional Information or Comments

Click on the "Submit Quote Request" button below to send your
Arizona Commercial Auto Insurance quote request.**

**Information received from this Arizona Commercial Auto Insurance quote request form
sent to Arizona Insurance Clinic will be for our use only and will not be sold, given to,
or distributed to any other parties. A quote will be based on the Arizona commercial auto
insurance information provided and does not guarantee acceptance of the risk by us.
The precise coverage afforded is subject to meeting underwriting guidelines, and the terms,
conditions and exclusions of the policy as issued. By submitting this request you
acknowledge that this is neither an offer to insure nor a guarantee of insurance.
Completion of this form does not entitle your business to an Arizona Commercial Auto
Insurance policy. We are licensed in Arizona and will not provide commercial auto
insurance quotes for other states.

Arizona Commercial
Auto Insurance Quote
We provide low cost
Arizona Commercial Auto
Insurance coverage
services throughout the
Grand Canyon State!
Arizona Insurance Clinic of
Tucson, AZ offers
comprehensive commercial
insurance coverage options and
affordable business insurance
services throughout Arizona.
Contact us about Arizona
Commercial Auto, Commercial
Property, Builders Risk,
Workers Compensation, and
Small Business Liability
Insurance at (520) 323-6887.

In addition to Arizona
Commercial Auto Insurance
quotes, we also offer
affordable Commercial
Property Insurance quotes.
We are a Tucson, AZ insurance agency offering affordable Arizona
commercial auto insurance quotes for your large or small
business located in the following cities and counties throughout the
Grand Canyon state of Arizona: Oro Valley, South Tucson, Cortaro,
Vail, Sahuarita, Benson, Sonoita, Elgin, Green Valley, Sierra Vista,
Continental, San Xavier, Madera Canyon, Patagonia, Nogales,
Tubac, Amado, Carmen, Pan Tak, Rillito, Redington, Marana, Red
Rock, Picacho, Oracle, San Manuel, Mt. Lemmon, Catalina,
Mammoth, Eloy, Casa Grande, Arizona City, Coolidge, Florence,
Gilbert, Peoria, Glendale, Sun City, Maricopa, Sun Lakes, Chandler,
Mesa, Scottsdale, Sun City West, Tempe, Phoenix, Apache
Junction, Surprise, Cochise County, Santa Cruz County, Graham
County, Pinal County, Maricopa County, and Pima County, AZ. We
can also provide your small business with a lower Arizona
commercial auto insurance quote in the cities of Flagstaff, Prescott
Valley, Yuma, Lake Havasu City, Sedona, Bullhead City, and
Prescott, AZ.
Arizona Business Information:
Your Arizona Commercial
Auto Insurance Quote Source
Arizona Insurance Clinic
4925 5th Street
Suite 101
Tucson, Arizona 85711
Pima County AZ
(520) 323-6887
Fax: (520) 323-9665
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