Contact Information

We are located at:
5201 Blue Lagoon Dr.
Penthouse Suite,
Miami, FL 33126

Toll-free:
877-674-2366
Tel:
305-444-3692
Fax:
305-460-3692
Email:   MrInsurance@DozaIns.com

Business Auto Insurance

Registration Name
Contact Name*
Address
Telephone*
Fax
Cell
E-Mail*
Use of Vehicle
Years in Business
Corporation Individual Partnership
Tickets or Accidents (last 36 months)
   List All
If yes, driver's name & reason
Prior Insurance
If yes, previous carrier, policy number
Expiration
Claims
Covered by workers compensation

LIMITS / COVERAGE
Liability Limits
Unisured Motorist
Compresive/Collision Deductible
Other Coverages

VEHICLES
Auto #1 Make
Model
Year
Boxed
Gross Vehicle Weight
Radius
Wheel Drive Type
ID/VIN#
Cost New
Auto #2 Make
Model
Year
Boxed
Gross Vehicle Weight
Radius
Wheel Drive Type
ID/VIN#
Cost New
Auto #3 Make
Model
Year
Boxed
Gross Vehicle Weight
Radius
Wheel Drive Type
ID/VIN#
Cost New

       * Denotes required field