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(276) 644-3589
2201 Lee Hwy Bristol, Virginia 24201
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Insurances Provided
Personal Insurance
Auto Insurance
Homeowners Insurance
Motorcycle Insurance
– View All Personal
Business Insurance
Commercial Auto Insurance
Commercial Property Insurance
General Liability Insurance
Workers’ Compensation Insurance
– View All Business
Life Insurance
Individual Life Insurance
Final Expense Insurance
Fixed Annuities
Mortgage Protection Insurance
– View All Life
Medicare Supplements
Medicare Part A
Medicare Part B
– View All Medicare
I Am…
An Individual or Family
Single Adults
Married Couples with Children
Empty Nesters
– View All
About
About Us
Meet Our Team
Customer Reviews
Insurance Companies
Insurance Blog
Services
Online Billing & Payments
File A Claim
Auto ID Card Request
Certificate of Insurance Request
Commercial Driver Questionnaire
Policy Change Request
Annual Insurance Review
Insurance Resources
Contact
Bristol Office
Secure Contact Form
Refer a Friend
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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
*
MM slash DD slash YYYY
Date of Birth
*
MM slash DD slash YYYY
Commercial Driver's License?
Commercial Driver's License?
Yes
No
Date Hired
MM slash DD slash YYYY
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?
*
(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? *
Yes
No
(1) Material misrepresentation in application or in submission of claims?
*
(1) Material misrepresentation in application or in submission of claims? *
Yes
No
(2) Suspension, revocation or expiration of operator's license of named insured or principal operator?
*
(2) Suspension, revocation or expiration of operator's license of named insured or principal operator? *
Yes
No
(b) Been required to file evidence of financial responsibility in the past 5 years?
*
(b) Been required to file evidence of financial responsibility in the past 5 years? *
Yes
No
(d) Received a ticket for speeding, a PBJ (PJC in NC), or any other vehicle code violation within the past 5 ears?
*
(d) Received a ticket for speeding, a PBJ (PJC in NC), or any other vehicle code violation within the past 5 ears? *
Yes
No
(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.
*
(e) Ever receive any felony convictions? Give date, description and penalty. *
Yes
No
(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.
*
(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. *
Yes
No
(g) Had any comprehensive losses (deer, fire, glass breakage, theft, etc.) in the past 5 years?
*
(g) Had any comprehensive losses (deer, fire, glass breakage, theft, etc.) in the past 5 years? *
Yes
No
(h) While driving any motor vehicle, commercial or personal, been involved in an accident during the past 5 years?
*
(h) While driving any motor vehicle, commercial or personal, been involved in an accident during the past 5 years? *
Yes
No
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?
5. Does driver take home any company autos on a regular basis?
Yes
No
If yes, what vehicles?
6. Does driver have any restrictions on license?
6. Does driver have any restrictions on license?
Yes
No
If yes, what are the restrictions?
Were MVRs/CLUEs ordered on any/all drivers?
Were MVRs/CLUEs ordered on any/all drivers?
Yes
No
Attach Copies
Max. file size: 49 MB.
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5/5
Great service...
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5/5
Such a great staff and company to work with!
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Fast, easy, friendly. Plus much better coverage than I had before, at a good
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Your staff including you are very helpful and friendly. You feel like your
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I am the son of Betty Silva. We came to you to get a price on ensuring my mom's
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