“Our office is available 24 hours, 7 Days a week. Post Coronavirus, we mainly operate remotely and we are available in our office by appointment. We have several representatives available to take care of your needs however we understand the need to sometimes come into our place of business in order for you to meet with one of our Protection Specialists and discuss your concerns. We highly value the person to person relationship and are readily available to meet with you in person”.
888-995-6019 Office No Ext. 813-995-6013 x 101 Direct.
Email: info@centurioninsuranceafs.com

Business Auto Supplemental Questionnaire





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    IndividualPartnershipCorpOther


    YesNo


    Historical Business Auto Insurance Policy Information


















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    Underwriting Questions


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    Click here if NO for allDriving while intoxicated or under the influence of drugsNegligent homicide arising from the use of a motor vehicleEluding or attempting to elude a police officerUsing a motor vehicle in the commission of a felonyMore than 3 moving violations in the past three (3) yearsOperation of vehicle during a period of suspension or revocationRefusing a drug or alcohol testAggravated assault with a motor vehicleSpeeding ContestPermitting an unlicensed person to drive a vehicleHit and Run AccidentReckless driving


    Click here if NO for allTaxiLimousineBusVan PoolCourtesy VehicleFuel, Gas, Oil or other Hazardous MaterialsDrive or Haul Away Vehicles and OperationsIndividually Owned VehiclesFarm VehicleMobile HomesTrucker or Bobtail OperationsAuto Dealer or Dealer Plated VehiclesAmbulance, Medic or EMT VehiclesDriver Training VehicleFire Trucks or Fire Response VehiclesVehicles rented or leased to Others

    Signature Section





    Notice to applicants: this application must be completed in full as the quote will be based solely on the information provided. Any person who
    knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information, or
    conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. By
    signing this application, the signor warrants that to their best knowledge all information given is true and accurate.
    Important Note : If this application is accompanied with a complete acord application that includes the business
    auto section and commercial auto driver information schedule, there is no need to complete this section.

    Garage Locations - we need the garage addresses of ALL rated vehicles

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