Florida Department of Management Services - DMS



Department of Management ServicesCommercial Automobile Insurance ApplicationThis policy is managed by the Department of Management Services. All applications for coverage must be sent to the contract manager listed on the insurance contract webpage to confirm eligibility. Once confirmed, the application will be forwarded to the Broker; the applicant will be copied on the email.Agency Name and Mailing Address: FORMTEXT ?????Contact Person: FORMTEXT ?????Telephone Number: FORMTEXT ????? FORMCHECKBOX Coverage Endorsement FORMCHECKBOX Quote Only (see *, below) FORMCHECKBOX Add Automobile FORMCHECKBOX Remove Automobile FORMCHECKBOX Add Driver FORMCHECKBOX Remove DriverEffective Date FORMTEXT ?????Automobile InformationYear*Make*Model*VIN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Garaged County*Vehicle Value*Driving Radius (mi) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Primary Driver InformationLast NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Driver Information(if applicable)Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameDate of BirthDriver’s License # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????All applications for coverage must be sent to the contract manager listed on the insurance contract webpage for processing. ................
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