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GEDMINAS INSURANCE and FINANCIAL SERVICES
This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Commercial Auto insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
   
Auto Fact Finding Questions
Of the following, what is the primary reason for a quote request? Requesting More Information 
Loan Required 
Replace Investment 
Liability Protection 
In the order of importance, what is most important to you? Price 
Service 
Proper Coverage 
Approximately when was the last time you did a review with your agent? Within the year 
Over 2 years ago 
Over 5 years ago 
Never 
Would you be interested in going to higher deductibles to reduce your premium? Yes 
No 
In the event of a lawsuit, accident, or judgment would you want to: Maximize Protection 
Assume Some Risk 
In the event of an untimely death, is it important to you that you're surviving spouse and/or children maintain the quality of life you currently have together without debt? Yes 
No 
Would you be interested in combining your commercial insurance for additional savings? Yes 
No 
If health insurance is provided for employees, would you like to save money? Yes 
No 
Requesting More Information 
Has your current company/agent failed to meet your expectations in any way? Yes 
No 
What else must I do to earn your business?
   
* Required Information
Contact Information
First Name
Last Name
Business Name
Gender Male     Female 
Date of Birth
Marital Status
State Licensed
Driver's License #
License Status
Business Address
Zip Code
Best Time To Call
Home Phone
Work Phone
Cell Phone
Fax
* Email
* Web Address
 
 
Vehicle Information
Are there any vehicles least to others? Yes     No 
Are there any hold harmless agreements required? Yes     No 
Are Any Vehicles Used to Transfer Public? Yes     No 
Are there Courtesy Vehicles? Yes     No 
Any Specialty uses or is Sponsoring of Special Events? Yes     No 
Any High Value Good Subject to Theft? Yes     No 
Do Any Vehicles Have Specialty Equipment Permanently Mounted? Yes     No 
Any Vehicles Customized or Altered? Yes     No 
Liability / Property Damage
Medical Payments
Comprehensive Deductible
Collision Deductible
Non Owned Auto Liability Yes     No     More Info Needed 
Hired Auto Liability Yes     No     More Info Needed 
Hired Auto Physical Damage Yes     No     More Info Needed 
Drive Other Car Yes     No     More Info Needed 
Optional Coverages
Audio Visual and Electronic Yes     No     More Info Needed 
Lease and Loan Yes     No     More Info Needed 
Fellow Employee Yes     No     More Info Needed 
Driver 1 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 2 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 3 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 4 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 5 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 6 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 7 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 8 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 9 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Driver 10 Information
Full Name Gender Male     Female 
State Licensed License Number
Date of Birth Social Security Number
Vehicle 1 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 2 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 3 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 4 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 5 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 6 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 7 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 8 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 9 Information
Year
Make
Model
VIN Number
Vehicle Usage
Vehicle 10 Information
Year
Make
Model
VIN Number
Vehicle Usage
Additional Information
Additional Information
   

Gedminas Insurance Services • CA LIC: 0E66327
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