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Lic # 0D44460

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Galaxy Insurance Service Inc
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Commercial Auto Quote

Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

Applicant Name
Home Phone
City
Drivers Name
Garage Address
State
Zip Code
Gender
Marital Status
Minor Violation in 36 Months
Bold = Required field
Work Phone
Mobile Phone
Fax
Mailing Address
City
Zip Code
D.O.B.
Number of Years Driving Experience
Major Violation in 36 Months
60 Months
60 Months
At Fault Accident in 36 Months
VEHICLE INFORMATIONS 1
Model Year
Make
Model
VIN
Vehicle Gross Weight if Commercial
Radius of Operation if
Company Type
Business Type
Value of Vehicle
Contact Person
Body Type
TRAILER
Make
Model Year
Type
Value of Vehicle
LIMITED OF COVERAGE

Bodily Injury / Person Bodily Injury / Occurrence

Property Damage

Medical Payment

Uninsured Motorist Liability

Bodily Injury / Person Bodily Injury / Occurrence

Property Damage

Collision Deductible

Other Then Collision Deductible (Comprehensive)

On Hook

Value of Vehicle
Type
Model Year
Make
TRAILER
Body Type
Value of Vehicle
Radius of Operation if
Vehicle Gross Weight if Commercial
VIN
Model
Make
Model Year
VEHICLE INFORMATIONS 2

Other Then Collision Deductible (Comprehensive)

Collision Deductible

LIMITED OF COVERAGE
LIMITED OF COVERAGE

Collision Deductible

Other Then Collision Deductible (Comprehensive)

VEHICLE INFORMATIONS 3
Model Year
Make
Model
VIN
Vehicle Gross Weight if Commercial
Radius of Operation if
Value of Vehicle
Body Type
TRAILER
Make
Model Year
Type
Value of Vehicle
LIMITED OF COVERAGE

Collision Deductible

Other Then Collision Deductible (Comprehensive)

VEHICLE INFORMATIONS 4
Model Year
Make
Model
VIN
Vehicle Gross Weight if Commercial
Radius of Operation if
Value of Vehicle
Body Type
TRAILER
Make
Model Year
Type
Value of Vehicle
Effective Date
SR22 / SR1 Filing
Yes
No
License Suspended / Interrupted within 36 Months
Yes
No
Hire Auto
Yes
No
None Owner Auto
Yes
No
Phone Number
Additional Information:
Email Address