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12641 Rosedale Highway
Bakersfield, CA 93312

(661) 554-9022

info@vineinsuranceagency.com

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Auto

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Home

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Life Insurance

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Commercial Auto

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Trucking Insurance

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General Liability

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Workers Compensation

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E&O / Professional Liability

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Home Warranty

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Pet

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Surety Bonds

AUTO INSURANCE

1. AUTO INSURANCE (PERSONAL AUTO)

ABOUT YOU

Full Name

Date of Birth

Phone Number

Email

Residential Address

Different mailing address?

Yes

No

Mailing Address

If you are human, leave this field blank.

HOMEOWNERS INSURANCE

11. HOME WARRANTY

Full Name

Phone

Email

Property Address

If you are human, leave this field blank.

RENTERS INSURANCE

3. RENTERS INSURANCE

Full Name

DOB

Phone

Email

Address

Type

Apt

House

Condo

Pets?

Yes

No

If you are human, leave this field blank.

Life Insurance

4. LIFE INSURANCE

Full Name

DOB

Phone

Email

If you are human, leave this field blank.

LANDLORD INSURANCE

5. LANDLORD INSURANCE

Full Name

Phone

Email

Mailing Address

If you are human, leave this field blank.

COMMERCIAL AUTO INSURANCE

6. COMMERCIAL AUTO INSURANCE

Business Name

Business Type

Motor Carrier / For Hire?

Yes

No

Entity Type

Years in Business

FEIN

Owner Name

Owner DOB

Phone

Email

Mailing Address

Garaging Address

Same as mailing

Same as mailing

If you are human, leave this field blank.

TRUCKING INSURANCE

7. TRUCKING INSURANCE

Business Name

Business Type

Motor Carrier / For Hire?

Yes

No

Entity Type

Years in Business

FEIN

Owner Name

Owner DOB

Phone

Email

Mailing Address

Garaging Address

Same as mailing

Same as mailing

If you are human, leave this field blank.

GENERAL LIABILITY (GL)

8. GENERAL LIABILITY

Business Name

DBA

Years in Business

Business Address

Different mailing address?

Different mailing address?

Mailing Address

FEIN

Primary Contact

Name

DOB

Phone

Email

If you are human, leave this field blank.

WORKERS COMPENSATION (WC)

9. WORKERS COMPENSATION (WC)

Business Name

DBA

FEIN

Years in Business

Business Address

Different mailing address?

Yes

No

Mailing Address

Primary Contact

Name

DOB

Phone

Email

Website (optional)

If you are human, leave this field blank.

Errors & Omissions / Professional Liability

10. E&O / PROFESSIONAL LIABILITY

Business Name

DBA

Years in Business

Business Address

Different Mailing Address?

Yes

No

Mailing Address

FEIN

Primary Contact

Name

DOB

Phone

Email

Website

If you are human, leave this field blank.

HOME WARRANTY

11. HOME WARRANTY

Full Name

Phone

Email

Property Address

If you are human, leave this field blank.

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