Vern Fonk Insurance

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Commercial/Contractor's
Liability Insurance

 


Surety and Contract Bonds


 

Commercial Liability Quote Request

STOP! Our internet customers can go to the front of the line!

Vern Fonk Insurance gives our internet customers special attention by sending them to the front of the line. Please call Marc Perez at 206-859-4894 during business hours: 9am - 6pm, Monday through Friday and 9 am - 2 pm on Saturday for immediate assistance on your commercial vehicle insurance needs.

Internet customers only!


Please fill out the form below and we will contact you with an insurance quote and answer any questions you have. Required fields are marked with a * , however to receive the most accurate quote we prefer that you answer all the questions.

*Before starting: Please select the city nearest you!

*How did you hear about us?

Tell Us About Your Company
*Company Name:
*Contact Name:
*Day Phone:    –   ext.
*Address:
*City:
*State:  
*Zip code:
Cell Phone:    –   ext.
*Email:
Current Insurance Company (if applicable):
How long have you been with your current provider: /yrs /mo
*Year business established:
Please describe your business:
Please describe type of cargo hauled(if applicable):
Prior Insurance Claims/Losses? Yes     No
Please describe claim(if applicable):

Additional Drivers
If you are insuring drivers other than yourself including your spouse, please fill out their information below. If you need to insure more than 4 drivers, please make note in the comments area at the bottom of the form.
First Name Date Of Birth Licensed
 /  /   /yrs
 /  /  /yrs
 /  /  /yrs
 /  /  /yrs

Driving Violations
*How Many Violations or Accidents have you had in the last 3 years?
Please specify violations for the drivers above. If there are more than 8 violations, please make note in the comments area at the bottom of the form.
Driver's Name Violation Date of Violation
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 

Need A SR-22?
If you need an SR-22 filing, please indicate the State here.

Tell Us About Your Vehicles
*If you have more than 3 vehicles, please make note in the comments area at the bottom of the form.

Vehicle One
*Year:
*Make:
*Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Two
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Three
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Coverage Information
*Liability:
*Uninsured Motorist:
*Personal Injury Protection:

Additional Information
Please provide any additional driver, vehicle or violation information
that will help us process your Insurance Quote:

Contact Options
*How should we reach you?
Day Phone   Cell Phone