Auto Insurance Quote Request
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7 - Automobile Insurance
In order to accurately price auto (car) insurance, we need the following information to get you all the discounts you can qualify for. A copy of your current policy is needed and can be submitted at the bottom of this form. . Once I get this information I will submit it to several companies to compare pricing and coverages.
ALL INFORMATION PROVIDED HERE WILL BE SENT to us SSL - SECURE SOCKET LAYER - ENCRYPTED for your security.
Today's Date
MM
/
DD
/
YYYY
Name as on Auto Title
Phone Number
*
###
-
###
-
####
Email
*
Who told you about us?
*
Who currently insures your cars?
*
What is your expiration date?
*
What will we discover on your Motor Vehicle Record for the past 5 years
*
Garaging Address Need Street #, City, State, Zip
(use comments section below if more than one garaging address)
Social Security # of Primary driver
All Drivers Occupations
(please be specific)
*
All Drivers highest DEGREE of education:
(increased discounts for higher education)
*
List each vehicle:
Year, Make, Model, VIN# and annual mileage
(ie: 2012 Honda Accord, #1HGCP2F78CA000459 10,000 miles)
*
Driver # 1. Name, Date of Birth, Drivers License # and Primary driver on what car, use (ex. back and forth to work work or pleasure)
*
Driver #2. Name, DOB, DL # and Primary on what car use (ex. back and forth to work work or pleasure)
Driver #3.Name, DOB, DL # and Primary on what car use (ex. back and forth to work work or pleasure)
Driver #4. Name, DOB, DL # and Primary on what car use (ex. back and forth to work work or pleasure)
Driver #5. Name, DOB, DL # and Primary on what car use (ex. back and forth to work work or pleasure)
Is any vehicle used for business purposes?
*
Yes
No
If yes, please describe specifically:
Are vehicles owned or leased?
*
Owned
Leased
Financed
Does any vehicle have a lienholder?
Yes
No
If yes, which one(s)?
How long have you been insured with your current carrier?
*
Any bankruptcies or foreclosures in the past 7 years
*
Do you carry an Umbrella or Excess Liability policy?
Do you own a home?
*
House
Condo
Mobile Home
N/A
Who is your current Homeowners Insurance provider?
Attaching a copy of your current Auto Policy declarations page here will eliminate the need for you to complete the below coverage requirements.. Otherwise we will need the below completed.
BODILY INJURY
Liability Limits
10,000/20,000
25,000
25,000/50,000
50,000
50,000/100,000
100,000
100,000/300,000
250,000
250,000/500,000
500,000
PROPERTY DAMAGE
Liability Limits
10,000
20,000
25,000
50,000
100,000
250,000
MEDICAL PAYMENTS Limit
1,000
2,000
5,000
NONE
UNINSURED MOTORIST Liability Limits
10,000/20,000
25,000
25,000/50,000
50,000
50,000/100,000
100,000
100,000/250,000
250,000
250,000/500,000
500,000
NONE
COMP/COLLISION Deductibles
250/250
250/500
500/500
500/1,000
1,000/1,000
1,000/2,500
2,500/2,500
2,500/5,000
NONE
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