Livery Exchange
Preliminary Insurance Survey

General Information
Company Name
DBA
Address
City	State Zip
Phone #	Fax #
Contact Person	Title
Email Address

Information about your business
# years in business
# of vehicles
Vehicle Type and Number	Sedans Stretches Minibus Vans Others
type of operation	Airport Charter Weddings Nights Out

Current Insurance Policy Information
	Current Insurance Co.	Expiration date	Premium
Commercial Auto
Umbrella
General Liability
Worker's Comp

Worker's comp Experience Modification

# of employees

Additional Comments