Commercial Driver Questionnaire

Any person who knowingly files an application containing any false, incomplete or misleading information, may be subject to criminal and/or civil penalties.

By submitting this form, you certify that you have given true and complete answers to the questions on this form. You have also given Weis Insurance Agency, LLC and Our Company Partner your permission to obtain a copy of your motor vehicle driving report for purposes of determining your eligibility for coverage under the policy and insured listed on the form submission.

As policyholder you are giving Weis Insurance Agency, LLC and Our Company Partner your permission to obtain a copy of the employee or potential employees motor vehicle record on your behalf.

Personal Information

Company Name *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Alternate Phone Number

E-Mail Address *

Current Insurance Provider

Policy Number *

Name of Driver (First, Last) *

Driver Information

Gender *

Date of Birth *

License Number *

Is the Driver regularlly supplied a vehicle to drive? *

Does this driver have any major violations or claims in the last five years?

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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