370 West Park Avenue, P.O.Box 9004, Long Beach, NY 11561-9004
Toll-free: 800-782-8902 Fax: 516-889-5111

Vanpool Preliminary Survey

This survey creates no express or implied obligation on our part to offer a quote or
provide insurance as requested. We may request you to complete a more detailed
application with the assistance of a Lancer authorized insurance producer.

General Information
Company Name :
D. B. A. :
Address :
City :   State :   Zip :
Phone # :   Fax # :
Contact Person :   Title :
Email Address :
Website :

Information About Your Vanpool
# of Years in Business :       # of Vans :
Type of Vehicles : Private Passenger
Vans
Buses
Limos
Describe how your vehicles are used:

Current Insurance Policy(s) Information
 
Current Insurance Co.
Expiration Date
Premium
Commercial Auto
$
 
Agent/Broker Name :
Address :
City :
  State :   Zip :
Phone # :
  Fax # :
E-mail Address :
Contact Person :

Additional Comments


The Preliminary Insurance Survey is copyrighted and material appearing within may not be reproduced in any form without the written permission of
Lancer Insurance Company.

© Lancer Insurance Company, 1997