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Vehicle Information:

List each vehicle that you will be using for your business.

If you need to list more vehicles, please fill out another form.

Registered Owner:

Address:

City:

State:

State Registered in:

County:

Year:

Make:

Model:

Body Type:

VIN:

Gross Vehicle Weight Rating in pounds:

Purchase Price:

Current Value:

Date of Purchase:

Vehicle Purchased: New Used

Percentage of Trips Made: 0 to 50 Miles 51 to 500 Miles 501 and Over

Liability Limits: $1,000,000 Combined Single Limit (CSL) PIP or Medical at $5,000

Types of Coverage Requested: Comprehensive Collision Liability Only

Comprehensive Deductible: $250 $500 $1,000

Collision Deductible: $250 $500 $1,000

Is there any damage to this vehicle: Yes No

If yes, please describe:

Will this vehicle be used for personal use? Yes No

If there is a loan against the vehicle, complete the section below:

Name of Lien Holder

Address of Lien Holder:

City:

State:

Zip Code:

Loan Number:

City

State

Zip Code

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801-488-0085

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2725 E Parleys Way Ste 170
Salt lake city, UT 84109
Ph: 801-488-0085 | charley@cayias.com

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