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Home > Policy Service Center > Motor Vehicle Request Form

Motor Vehicle Request Form

Thinking about hiring a new driver for your business, click on the link below and have your potential new hire complete this form and we will let you know if they are approved to drive the same day.

Commercial Driver Questionnaire

Policyholder's Name
First Last
Policy Number
Agent No.
Agent Name
First Last
Policyholder's Address
Street Address City State / Province / Region ZIP / Postal Code
Driver Information
Driver's Name
First Middle Last
- Male
- Female
License Number
State
Prior State And Operator's Number If Less Than 3 Years
Date First Licensed or Date of Permit
Date Format: MM slash DD slash YYYY
Date of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Commercial Driver's License?
- Yes
- No
Date Hired
Date Format: MM slash DD slash YYYY
Driver's Auto Insurance Company
Home Phone Number
3. 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?
- Yes
- No
Details for "Yes" answer*
OHIO ONLY: Had any auto insurance refused, cancelled or expired for:
(1) Material misrepresentation in application or in submission of claims?
- Yes
- No
Details for "Yes" answer*
(2) Suspension, revocation or expiration of operator’s license of named insured or principal operator?
- Yes
- No
Details for "Yes" answer*
(b) Been required to file evidence of financial responsibility in the past 5 years?
- Yes
- No
Details for "Yes" answer*
(c) Had their driver’s license or driving privileges revoked or suspended in the past 5 years?
- Yes
- No
Details for "Yes" answer, including date and reason*
(d) Received a ticket for speeding, a PBJ (PJC in NC), or any other vehicle code violation within the past 5 years?
- Yes
- No
Details for "Yes" answer, including give date and description of violation(s). If speeding, include your actual speed and the speed limit*
(e) Ever receive any felony convictions?
- Yes
- No
Details for "Yes" answer, including date, description and penalty*
KY ONLY: Ever been arrested and convicted for arson, insurance fraud, a crime involving dishonesty or the misappropriation of funds, or for a criminal offense while using a motor vehicle in the past 10 years?
- Yes
- No
Details for "Yes" answer*
Had a physical or mental impairment or disability or other medical infirmity?
- Yes
- No
Details for "Yes" answer, including identifying 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?
- Yes
- No
Details for "Yes" answer*
(h) While driving any motor vehicle, commercial or personal, been involved in an accident during the past 5 years?
- Yes
- No
Describe all accidents regardless of who was at fault*
(i)FOR MD ONLY: Refused to submit to a chemical test or been given probation before judgment for an alcohol violation in the past 3 years?
- Yes
- No
Details for "Yes" answer*
(NOTE FOR DC ONLY: Question 3(a) not applicable. For questions (b), (c),(d), (g), (h) & (i), ask for 3 year record only.) (NOTE FOR MD ONLY: For Questions 3 (a), (b), (c), (d), (g), (h) & (i) ask for 3 year record only.) (NOTE FOR WI ONLY: Question 3(f) not applicable.)
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?
- Yes
- No
What vehicle(s)?
6. Does driver have any restrictions on license?
- Yes
- No
What are the restrictions?
7. Were MVRs/CLUEs ordered on any/all drivers?
- Yes
- No
Attach copies
Drop files here or
8. Other Pertinent Information
PLEASE READ:
DC APPLICANT(S): WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
KY APPLICANT(S): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
MD APPLICANT(S): Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NY APPLICANT(S) (Fraud Warning): Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
OHIO APPLICANT(S): Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
PA APPLICANT(S): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
TN & VA APPLICANT(S): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WV APPLICANT(S): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
OTHER APPLICANT(S): Any person who knowingly files an application containing any false, incomplete or misleading information, may be subject to criminal and/or civil penalties.
Commercial Driver's Signature
I certify that I have given true and complete answers to the above questions. You have my permission to obtain a copy of my motor vehicle driving record for purposes of determining my eligibility for coverage under this policy
Date
Date Format: MM slash DD slash YYYY
Policyholder's (or Authorized Representative's Signature)
Date
Date Format: MM slash DD slash YYYY
Title

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Quinton Insurance

2700 Elmwood Avenue
Rochester, New York 14618

Phone: (585) 244-9004

Fax: (877) 397-2856

Toll Free: (800) 454-1970

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