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or email TechRisks  24/7
Toll: 866.355.Risk (7475)  
Tel : 267.803.1371 or   
e-mail :
Auto Application
Legal Business / Name
Mailing Address:
Your E-Mail Address:
Your Phone Number:
Confirm the below:

VIN number(s)

Year, Make and Model of each vehicle

Current Mileage & Mileage driven
by each driver

All Drivers’ First Name: Middle
Initial: Driver's Last Name:  

All drivers: Date of Birth:

Their license state and license #’s

Where are vehicles garaged? We
Need address and zip code.  

Any tickets or accidents in the last
three (3-5) years? If yes, describe
with dates,  description of the incident
and loss amounts:

Were the cars purchased new?  If
yes, what is the replacement value.  

Do they have alarm systems or any

What limits and coverage would you

(If you have a copy of your
existing auto declaration page
this can help us determine some
of this info, including VIN, year,
make and model, etc.   Auto ID
cards also help,You can email
this info to:      )

You / your firm are unaware of any
past claims or losses insured or
otherwise in the last 5 years,  you /
your firm is also unaware of any
circumstances which could give rise
to a claim.  If this is not true, please
provide details here.

Addition comments or thoughts:.
Provide a brief description of your firm  
(for example we are an it consulting firm
that does MSP and VAR work)
Year Incorporated / Established
FEIN Number
If you are not eligible for the Progressive option or To obtain an alernative quote
for a
uto insurance, please confirm the below:
I hereby declare that I am authorized to complete this application on behalf of the applicant and that after
due inquiry, to the best of my knowledge and belief, the statements and particulars are true and complete
and no material faces have been misstated, suppressed or omitted.  I undertake to inform underwriters or
addition to these statements or particulars which occur before or during any contract of insurance based
on the applications is effected.  I also acknowledge that this application (together with any information
supplied to underwriters) shall be the basis of contract.

I understand that underwriters will rely on the statements that I make on this form.  In this context, any
insurance coverage that may be issued based upon this form will be void If the form contains falsehoods,
misrepresentations or omissions.   Click here to submit and agree to this declaration.
Progressive Auto Quotes for FL,
GA,IL,PA, NJ, VA and WA Clients:  
(all others complete the below) is service mark of and insurance program operated by Drawbridge Insurance Services, LLC; (CA License #0F00765) and in NY, Drawbridge Insurance Brokerage. Coverage availability may
vary by state.  Any coverage summaries are for illustrative purposes only and should in no way be considered a complete and final summary of any insurance coverages available or provided.  All policies
are subject to policy terms, conditions, exclusions and final insurance carrier underwriting approval.

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