F. A. Peabody Company
Truck Insurance Quote Form

F. A. Peabody Company is licensed to do business in the State of Maine ONLY with offices in
Houlton, Caribou, Hampden, Lincoln, Mars Hill, Presque Isle, and Sherman Mills.   All information provided will be held CONFIDENTIAL and used only for responding to your quote request.
Completion of all fields will provide you with the most accurate quote.
(Required Fields indicated by *)
 CAUTION - Do Not hit ENTER - Use TAB key or mouse to move to next field.
General Information
*First Name:
*Last Name:
*Business Name
*Mailing Address:
*Garaging Address:  
*City:   State: ME    *ZIP:            
County:       *E-mail:            
Home Phone:              Work Phone 
Fax:                  Cell Phone
Best time to call: AM PM
Call home or work?: Home   Work     Mobile
Prefer contact by: Phone  Mail        E-Mail
STATE/FEDERAL Filings: Yes   No         MC/DOT#  
*Operations Information
Insured Routes are  Fixed Irregular

Operating
 Information
 

 

                             

                                 

Radius 0-100          %
       101-300          %
       301-500          %
     Over 500           %
(Total must equal 100%)
Estimated Annual Mileage  
Basis of Wages        
Largest Cities Entered
List 3		                        
                     
                     

Liability Limits

Bodily Injury/Property Damage:
Medical Payments:   Uninsured Motorists:
Cargo Limits
Cargo Limit:    Cargo Deductible: 
Commodities Hauled

 

  
Current Auto Insurance Coverage:
Company Name:
Policy Exp. Date:
Are you being cancelled: Yes   No
If yes, why?:
Premium: $
Losses Past 3 Years:            
Vehicle Information:
Veh #1 Year Make Model Body Type Vehicle ID# (VIN)
Collision Deductible:                                          Comprehensive Deductible:
Existing Damage:                 Value: 
If vehicle is kept at an address other than that listed above, please indicate:
Location City:    State:    Zip:
Veh #2 Year Make Model Body Type Vehicle ID# (VIN)
Collision Deductible:                                          Comprehensive Deductible:
Existing Damage:                 Value: 
If vehicle is kept at an address other than that listed above, please indicate:
Location City:    State:    Zip:
Veh #3 Year Make Model Body Type Vehicle ID# (VIN)
Collision Deductible:                                          Comprehensive Deductible:
Existing Damage:                 Value: 
If vehicle is kept at an address other than that listed above, please indicate:
Location City:    State:    Zip:
Veh #4 Year Make Model Body Type Vehicle ID# (VIN)
Collision Deductible:                                          Comprehensive Deductible:
Existing Damage:                 Value: 
If vehicle is kept at an address other than that listed above, please indicate:
Location City:    State:    Zip:
Driver Information:
(include all licensed drivers)
Driver's Name License Number Yrs Driving Experience Date of birth
(Mo/Day/Yr)
   
 
 
 
 
Driver History

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
    Yes   No
    If yes, please answer the following:

Driver Date Type of Conviction

2. Been involved in any accidents, regardless of fault, in the past 3 years?
    Yes   No
    If yes, please answer the following:

Driver Date Cost Injuries At Fault Description
$ Y
N		 Y
N
$ Y
N		 Y
N
$ Y
N		 Y
N
$ Y
N		 Y
N
Additional Comments:
Please give any additional comments about the coverage you desire:
 

THANK YOU for letting us serve your Automobile Insurance needs.
Your quote will be on its way to you very soon.