Be specific to tell if accidents are "at-fault" or "NOT-at-fault"
- (carriers require proof on NOT-at-fault accidents); Also,
be specific as to TYPE of violations, and approximate DATES
of each in the fields below:
Number & Type
of Accidents last 3 years:
Number & Type
of MINOR Cites last 3 years:
Number & Type
of MAJOR Cites last 3 years:
Daily commute
in ONE WAY miles:
Does
Driver need
an SR22 FILING?
Yes
No
If
YES to SR22 filing, why needed?
(list accident/cite)
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years
U.S.
Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault"
- (carriers require proof on NOT-at-fault accidents);
Also, be specific as to TYPE of violations in fields below:
Number &
Type of Accidents last 3 years:
Number &
Type of MINOR Cites last 3 years:
Number &
Type of MAJOR Cites last 3 years:
Daily commute
in ONE WAY miles:
Does Driver
need
an SR22 FILING?
Yes
No
Comments
or
Remarks?
VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make &
Model:
Annual Mileage:
Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits
of
Liability:
$15/30 BI / 10 PD
$25/50 BI / 25 PD
$50/100 BI / 25 PD
$100/300 BI / 100 PD
$250/500 BI / 100 PD
$500,000 CSL
Comprehensive
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Rental
Car &
Towing Coverage?
YES
NO
VEHICLE #2 INFORMATION
(if none, leave blank)
Year of vehicle:
Make &
Model:
Annual Mileage:
Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits
of
Liability:
$15/30 BI / 10 PD
$25/50 BI / 25 PD
$50/100 BI / 25 PD
$100/300 BI /100 PD
$250/500 BI /100 PD
$500,000 CSL
Comprehensive
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Rental
Car &
Towing Coverage?
YES
NO
Comments
or Remarks:
(List additional
drivers, autos, etc. here)
Send
my quotation via:
E-Mail
Fax
Regular Mail
Call me by Phone!
Thank
you for filling out this form COMPLETELY!
We value your
input as PRIVATE information. Every step has been taken to
insure your privacy, security, and our intent is to release
quote information only to you. We will not give your data
to ANY other person or group for sales, marketing, or ANY
other purposes. By checking the box below you agree to allow
our agency to release this information via the method you
have chosen, and to release us from any liability should this
information be accidentally viewed by others. Our intention
is to maintain your complete privacy.
Yes, I Agree. Please Send Me a
Life Insurance Quote NOW!
Click Button
Below When Done
Please Click Only Once . . . May take up to 30 seconds!
