370 West Park Avenue, P.O. Box 9004, Long Beach, NY 11561-9004
Toll-free: 800-782-8902 Fax: 516-889-9872

Auto Rental
Preliminary Insurance Survey
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Please answer all questions completely.
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The receipt of a completed application creates no express or implied obligation on the part of Lancer Insurance Company to offer a quotation or provide insurance as requested.
Today's Date:
E-mail Address:
Company Name:
Contact:
Address:
Street
 P.O. Box
City State Zip
Phone #: Fax #:
Years in Business:
# of Vehicles:
Insurance Co.:
Expiration Date:
Current Premium:
Coverage Req.:
 Auto Liability
 Comprehensive
 Collision
Liability Limit:
Deductibles:
 Comprehensive
Collision
Rating Basis:
 PCPM
 Gross Receipts
Annual Receipts:
 (Estimated)
Type of Rentals:
 % Business
% Pleasure
% Replacement
100%

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

© Lancer Insurance Company, 2008



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