Request for Quote

Automobile Insurance Quotation Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

(As part of our underwriting procedures, we order consumer reports relating to credit, driving record and loss history as allowed by law. Upon your request, we will advise you of the name and address of the consumer reporting agency from whom we obtain such reports.)

First Name: Last Name:
Current Address 1:
Current Address 2:
City, State, Zip:
County:	E-Mail Address:
Home Phone:	Work Phone: Fax No:

How would you prefer to be contacted regarding your quote? Phone Fax Mail E-mail

If by phone, best time to call is: AM / PM

How many years have you lived at the above address? Do you own a house, condo or coop? Yes No

If less than 2 years please supply your previous address:

Do you have current automobile insurance coverage?	Yes No If yes, what is your renewal date?
Insurance Company Name: How long have you been with them?
If "No", we need a reason why:

Current Coverage

Bodily Injury Limits:		Property Damage Limits:
Combined Single Limits (CSL):		Collision Deductible:
Medical Payments:		Towing Coverage:
Comprehensive Deductible:		Rental Coverage:
Uninsured/Underinsured Motorist Limits:

Vehicle Information

#	Year	Make & Model	Doors	Vehicle Identification #	Miles Annually	Anti-Lock brakes	Air Bags	Alarm	Driven to Work? How many miles?	Driven to School? How many miles?
1						Y N
2						YN
3						Y N
4						YN

Highest level of education for each driver:	Driver 1 Driver 2
	Driver 3 Driver 4

Which vehicles are used for business?	Vehicle 1	Do any vehicles have a lien or lease?	Vehicle 1
(pick up, delivery, etc.) (If any)	Vehicle 1		Vehicle 2
	Vehicle 3		Vehicle 3
	Vehicle 4		Vehicle 4

Driver Information of ALL household members

Any physical or mental impairments affecting your driving? Y N If yes, please explain:

Accidents, Tickets, Claims for the Last Five Years

	Date (MM/DD/YY)	Type of Traffic Violation, Accident or Claim Description	Driver Name	If Accident, tickets Issued?	Injuries?	Amount Paid for Injuries	Amount Paid for Vehicle/Property Damage
1
2
3
4

List Drivers Having Taken a Defensive Driving Class within the last 3 years:

Driver 1		Driver 3
Driver 2		Driver 4
Which drivers under 25 have taken a High School Driver Training course?

Comments/Questions