PBIA Digital Forms

Section 1 of 4

Business Information

Lookup License (CSLB)

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Business Name *

Contractors License / Application Fee Number

Business Phone Number *

Business Street *

Business City *

Business State *

Business Zip *

Business Email *

Federal Tax ID (EIN) *

Date Business Started *

Business Website (if none, enter NA) *

Brief Description of Business Operations *

Mailing address is the same as business

Section 2 of 4

Primary Contact

First Name *

Last Name *

Email *

Phone Number *

Preferred Method of Contact for Follow-Up *

EmailPhoneSMS / Text

Section 3 of 4

Vehicle 1

Make *

Model *

Year *

Vehicle Type *

Name this Vehicle is Currently Registered Under *

What is this vehicle going to be used for? *

Current Policy's Carrier (if applicable)

Will this vehicle be used by other employees or drivers?

YESNO

Is this vehicle presently covered under a personal auto insurance policy?

YESNO

Have you had uninterrupted personal auto insurance coverage during the last 4 years?

YESNO

Upload VIN *VIN must be a photo of the VIN on the actual vehicle.

Upload Vehicle Registration *

Section 4 of 4

Driver 1

Driver First Name *

Driver Last Name *

Driver's License Number *

Years of U.S. Driving Experience *

Employment Status *

Is this driver assigned to a specific vehicle?

YESNO

Upload Driver License *

All required fields are marked with *