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J Rush Insurance Group
1639 Cape Coral Pkwy E. # 103/104
Cape Coral, Florida 33904
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Phone: 239-344-7920
Fax: 239-344-7921
Toll Free: 877-820-7874
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Business & Commercial Auto Vehicle Insurance Quote

Contact Name:  
Business Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
 Fax:  
 

Vehicle Information
(List all cars you own/lease)
Vehicle 1:  
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 2:  
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 3:  
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 4:  
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Any Custom equipment of vehicles? (if YES, give their value):  
 

Current Insurance Information
Insurance Company Name:  
Policy Exp. Date:  
Premium Amt:  
Term:  
 How long with current?  
Debris hauled for others?:  
Trailer Hitch?:  
Liability Limit Requested:  
Class of Business:  
 

Driver 1
Name:  
Sex:  
DL #:  
Marital Status:  
Date of birth:  
Driver's Education?:  
S.S.# (optional):  
Defensive Driving:  
Years Licensed:  
Good Student:  
Occupation:  
SR 22 filing?:  

Driver 2
Name:  
Sex:  
DL #:  
Marital Status:  
Date of birth:  
Driver's Education?:  
S.S.# (optional):  
Defensive Driving:  
Years Licensed:  
Good Student:  
Occupation:  
SR 22 filing?:  

Driver 3
Name:  
Sex:  
DL #:  
Marital Status:  
Date of birth:  
Driver's Education?:  
S.S.#(optional):  
Defensive Driving:  
Years Licensed:  
Good Student:  
Occupation:  
SR 22 filing?:  

Driver 4
Name:  
Sex:  
DL #:  
Marital Status:  
Date of birth:  
Driver's Education?:  
S.S.# (optional):  
Defensive Driving:  
Years Licensed:  
Good Student:  
Occupation:  
SR 22 filing?:  

Accidents / Violations in the last 5 years?
Date
Driver
Violation
Cost ($)
List any DUI convictions, license suspensions or revocations:  

How did you hear about us?

Any additional comments or information that might be helpful in your quote:
Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.


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