Omega Insurance AgencyP:(631)923-2520F:(631)923-2522Commercial Auto Submission FormDate: MM slash DD slash YYYY Company: DBA: Contact Name: First DOT#: MC#: Address: Street Address Mailing: Phone:Fax: E-mail: Years in Business: Radius of Ops: IFTAS: Yes No Received: Owner's Name: First LOSS RUNS: Received: TAX ID# Commodities Hauled: Previous Insurance Carrier: Previous Insurance Premium: Expiration Date LIMITSLiability: General Liability: Trailer Interchange: Umbrella: Cargo: Reefer Breakdown: YES NO Physical Damage: YES NO VEHICLE LISTYear Add RemoveMake Add RemoveModel Add RemoveVIN# Add RemoveGVW/Seats Add RemoveStated Amount Add RemoveDRIVER LISTName Add RemoveDOB Add RemoveLicense# Add RemoveState Add RemoveDOH Add RemoveYears Experience Add RemoveUpload File: Drop files here or Select files Accepted file types: (iejpg, gif, png, pdf), Max. file size: 1 GB. Attachments Required • Copy of Drivers licenses • Loss runs • IFTA’s • Copy of certificate of insurance • Vehicle and driver schedules
