P.O.M. PLANNING SERVICES, INC

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Auto (Commercial)

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Legal Business Name * :

Address * :

Tax ID Number :

Business Type * :

Contact Telephone Number * :

Email * :

List of Drivers:

Name	DOB	License #	Issue State	SSN	Marital Status

Vehicle Information :

Year	Make	Model	VIN #

Vehicle usage :

Desired Liability limit :

State Minimum $50,000/$100,000 $100,000/$300,000 Other

Comp/Collision deductible :

$500 $750 $1,000

Current Auto-Insurance Carrier :

Expiration Date of Current
Insurance Policy :

Loss/Claim in the last 3 years :

Additional Information :