Due to the Coronavirus, our office will be operating remotely in order to keep our staff free from infection. For latest update on the virus as it pertains to Florida please access our link. Office: 813.995.6013 Ext: 101 / Direct: 727.755.3060 Email: info@centurioninsuranceafs.com

Business Auto Supplemental Questionnaire





    YesNo







    IndividualPartnershipCorpOther


    YesNo


    Historical Business Auto Insurance Policy Information


















    YesNo


    YesNo

    Underwriting Questions


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    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

    Loc # 1





    Loc # 2





    Loc # 3





    Loc # 4





    Vehicle Schedule 1








    Vehicle Schedule 2








    Vehicle Schedule 3








    Vehicle Schedule 4








    Driver Schedule 1









    Driver Schedule 2









    Driver Schedule 3









    Driver Schedule 4