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Automotive Insurance Quote

General Information
Name:
Address:
City:  State:  ZIP:
County:    Twp or Borough:
Phone Day: -           Night: -
Best time to call:  am  pm
E-mail:        Fax: -
Occupation:        How long at current job: years months
Spouses Occupation:        How long at current job: years months
How would you like to be contacted?

Current Auto Insurance Company (not agency):
Company Name:
Policy Exp. Date: / /
Premium: $
Have you had 6 months continuous insurance: Yes  No

Vehicle Information:
(include all cars you or your family members own or lease)
Car #1 Year Make Model Sub Model # Door Vehicle ID# (VIN)
19
Name of Title Holder
Annual Mileage
Drive to work or school?
Yes  No
# of miles (one way): 		# airbags:
0, 1, 2
Anti-theft device?
Yes  No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Vehicle Information:
(include all cars you or your family members own or lease)
Car #2 Year Make Model Sub Model # Door Vehicle ID# (VIN)
19
Name of Title Holder
Annual Mileage
Drive to work or school?
Yes  No
# of miles (one way): 		# airbags:
0, 1, 2
Anti-theft device?
Yes  No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Vehicle Information:
(include all cars you or your family members own or lease)
Car #3 Year Make Model Sub Model # Door Vehicle ID# (VIN)
19
Name of Title Holder
Annual Mileage
Drive to work or school?
Yes  No
# of miles (one way): 		# airbags:
0, 1, 2
Anti-theft device?
Yes  No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Vehicle Information:
(include all cars you or your family members own or lease)
Car #4 Year Make Model Sub Model # Door Vehicle ID# (VIN)
19
Name of Title Holder
Annual Mileage
Drive to work or school?
Yes  No
# of miles (one way): 		# airbags:
0, 1, 2
Anti-theft device?
Yes  No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Liability Limit for all Cars
Bodily Injury Property Damage Single Limit
25,000-50,000 25,000
50,000-100,000 50,000
100,000-300,000 100,000 100,000
300,000-300,000 250,000 300,000
250,000-500,00 500,000 500,000
Choose either Bodily Injury & Property Damage OR Single Limit

Liability Only or Full Coverage
Vehicle # Liability Only Comprehensive
Deductible		 Collision
Deductible		 Towing Rental
1

Yes
No

100250
500

250500
1,000

Yes
No

Yes
No
2

Yes
No

100250
500

250500
1,000

Yes
No

Yes
No
3

Yes
No

100250
500

250500
1,000

Yes
No

Yes
No
4

Yes
No

100250
500

250500
1,000

Yes
No

Yes
No

Driver Information:
(including all licensed drivers in your household)
Driver's Name Occupation Relation
to you		 Birthdate
(MM/DD/YY)		 Male/
Female 		Married/ Single Good
student
Discount
>3.0		 # years
Licensed 		Vehicle driver
uses most.
#1 #2 #3 #4
Self MF M
S		 Y
N
MF M
S		 Y
N
MF M
S		 Y
N
MF M
S		 Y
N
List any member of the household not of driving age or unlicensed. Name   Birthdate  
List any member of the household not of driving age or unlicensed. Name   Birthdate  

Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

In the past 5 years has any driver listed:

1. Been convicted of any moving traffic violation in the past 5 years?    

Yes   No

    If yes, please answer the following: (List all violations)
Driver Date
(Month/Year)		 Type of Violation Time Speed
Over Limit
/ MPH
/ MPH
/ MPH
/ MPH
/ MPH

2. Had his/her license suspended or revoked in the past 5 years?

    Yes No

If yes, please answer the following:

Driver Suspended Revoked Date
(Month/Year)
Yes Yes /
Yes Yes /
Yes Yes /
Yes Yes /

3. Ever been convicted of driving under the influence of alcohol or drugs?

Yes No    

If yes, please answer the following:

Driver Alcohol Drugs Date
(Month/Year)
Yes Yes /
Yes Yes /
Yes Yes /
Yes Yes /

4. Been involved in any accidents, regardless of fault, in the past 5 years?

    Yes  No

    If yes, please answer the following:

Driver Date
(Month/Year)		 Cost Citation At Fault Time Description
/ $ Y
N		 Y
N
/ $ Y
N		 Y
N
/ $ Y
N		 Y
N
/ $ Y
N		 Y
N

Additional Comments:
I would like more information on annuities/retirement planning yes no
I would like more information on life insurance yes no
Please give any additional comments about the coverage you desire: