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Name*
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Email*
Phone*

If you have a spreadsheet or declaration pages to upload, please upload here.
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Max. file size: 50 MB.

Policy Effective Date
MM slash DD slash YYYY
Driver Information
Name City State ZIP Code Sex Marital Status (Married, Single, Widowed) Date of Birth Drivers License Number License State

List all drivers, including family members that drive company vehicles, and employees who drive their own vehicles on company business.

Is there a vehicle maintenance program in operation?
- Yes
- No
Explain.

Any vehicles used by family members?
- Yes
- No
List the family members.
Does the applicant obtain MVR (Motor Vehicle Record) verifications?
- Yes
- No
Explain.

Do you have electronic monitoring devices that record and transmit data in any of your vehicles?
- Yes
- No
What percentage of vehicles in your overall fleet are monitored (1-100%)?
Please enter a number from 1 to 100.
Please indicate how you utilize the electronic monitoring devices (check all that apply).
- Monitor Driver Safety
- Navigation
- Track Fuel Consumption
- Monitor Vehicle Maintenance
- Mileage Tracking
- Location Tracking

Vehicle Descriptions
VEH # Year Make Model Body Type V.I.N. Vehicle Type (If trailer, what kind?) Radius COMP/OTC $ COLL $

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This site serves residents of the AAA Club Alliance service area which includes Greater Hartford, CT Area, Cincinnati Tri-State Area, Miami County, OH, Greater Dayton, OH Area, Northwest Ohio, AAA Blue Grass & Bluefield Regions, Southern West Virginia, Kansas, Oklahoma, South Dakota, Delaware, Maryland, Washington DC, and parts of Virginia, Pennsylvania, and New Jersey. Write Us: AAA Club Alliance, One River Place, Wilmington, DE 19801

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Josh Hass Insurance

Address

214 E Choctaw Ave.
McAlester, OK 74501

Hours

MON-THURS : 9AM - 5PM
FRIDAY : 9AM - 4PM

Phone

Email

office@joshhass.agency

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