Home > Commercial Driver Questionnaire

Commercial Driver Questionnaire

Commercial Auto Driver Questionnaire

* indicates required fields

Policyholder's Name*

Policy Number*

Agency Number

Agency Name

Policyholder's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Driver Information

First Name*

Middle Initial

Last Name*

License Number*

State*

Prior State and Operator's Number If Less Than 3 Years

Date First Licensed/Date of Permit*

Date of Birth*

Commercial Driver's License?

Date Hired

Job Title

Driver's Current Auto Insurance Company

Home Phone Number

WARNING: An incorrect answer, intentional or not, to any question below may jeopardize continuing coverage. If the answers to any of the following are "Yes", give details in space provided.

Has driver

(a) Had any auto insurance refused, cancelled or expired in the past 5 years? or been excluded or restricted on a policy in the past 5 years?*

(1) Material misrepresentation in application or in submission of claims?*

(2) Suspension, revocation or expiration of operator's license of named insured or principal operator?*

(b) Been required to file evidence of financial responsibility in the past 5 years?*

(d) Received a ticket for speeding, a PBJ (PJC in NC), or any other vehicle code violation within the past 5 ears?*

(IF "Yes," give date and description of violation (s). If speeding, include your actual speed and the speed limit.)*

(e) Ever receive any felony convictions? Give date, description and penalty.*

(f) Had a physical or mental impairment or disability or other medical infirmity? Identify any such condition (e.g., heart, diabetes, epilepsy, hearing, sight or limb loss, back condition or other medical infirmity), its duration and treatment obtained and/or medication prescribed.*

(g) Had any comprehensive losses (deer, fire, glass breakage, theft, etc.) in the past 5 years?*

(h) While driving any motor vehicle, commercial or personal, been involved in an accident during the past 5 years?*

Describe any accidents (regardless of who was at fault)

Details for "Yes" answers:

4. List driver's previous experience driving types of commercial vehicles insured and any safety courses completed

5. Does driver take home any company autos on a regular basis?

If yes, what vehicles?

6. Does driver have any restrictions on license?

If yes, what are the restrictions?

Were MVRs/CLUEs ordered on any/all drivers?

Attach Copies

Max. file size: 49 MB.

Other Pertinent Information

This field is for validation purposes and should be left unchanged.

Specializing In ERIE Insurance

Pay Your Bill

Access Online Account

We Want Your Opinion!

Customer Reviews

Rated 5 out of 5

Amanda was great! She helped us find the lowest rate possible!! Thank you all...

Savanna J

Rated 5 out of 5

Friendly and helpful people. They always greet you with a smile. Great...

Tammy d Clark

Rated 5 out of 5

Great people to do business with! Not only do I get immediate service when I'm...

Preston H

Fast, easy, friendly. Plus much better coverage than I had before, at a good

Ralph ( Hess

Your staff including you are very helpful and friendly. You feel like your

Jan F

Commercial Driver Questionnaire

Commercial Auto Driver Questionnaire

Driver Information

Has driver

Amanda was great! She helped us find the lowest rate possible!! Thank you all...

Friendly and helpful people. They always greet you with a smile. Great...

Great people to do business with! Not only do I get immediate service when I'm...

Fast, easy, friendly. Plus much better coverage than I had before, at a good

Your staff including you are very helpful and friendly. You feel like your

Contact

Insurance

About

Policy Service