I would like a quote on the following type(s) of insurance:

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AUTO INSURANCE

About your vehicles:

Year, Make, and Model of all vehicles :

(Example: 98 Chevrolet Cavalier)

Vehicle #1:		Select Coverage Level Full Coverage Liability Only
Vehicle #2:		Select Coverage Level Full Coverage Liability Only
Vehicle #3:		Select Coverage Level Full Coverage Liability Only
Vehicle #4:		Select Coverage Level Full Coverage Liability Only

 

About the drivers:

Your marital status:	Married Single	Your DL#
Gender:	Male Female
Your age:
Spouse's age:		Spouse DL#
Add'l Driver 1 age:		Driver 1 DL#
Add'l Driver 2 age:		Driver 2 DL#

About driving distance:

Vehicle	Driver	Miles to work	Miles to school
Vehicle #1	You Spouse Add'l Driver1 Add'l Driver2
Vehicle #2	NA You Spouse Add'l Driver1 Add'l Driver2
Vehicle #3	NA You Spouse Add'l Driver1 Add'l Driver2
Vehicle #4	NA You Spouse Add'l Driver1 Add'l Driver2

About driving records:

(# Tickets and Accidents last 3 years; DUI- 5 yrs)

Driver	Tickets	Accidents	DUI
You Spouse Add'l Driver1 Add'l Driver2 Add'l Driver3
NA You Spouse Add'l Driver1 Add'l Driver2 Add'l Driver3
NA You Spouse Add'l Driver1 Add'l Driver2 Add'l Driver3
NA You Spouse Add'l Driver1 Add'l Driver2 Add'l Driver3

 

About your current coverage:

Current Auto Insurer:
Payment Frequency:	Monthly Quarterly Semi Annual Annual
Next Payment Due:	Very Soon Soon In a few weeks In a few months Other

Additional Comments:

PROPERTY INSURANCE

If Homeowners, year house built:
If Homeowners, amount insured for:
Amount of "contents" coverage:
Zip Code:

Smoker/Nonsmoker Status

Yourself:

Smoker    Nonsmoker 

Spouse:

Smoker    Nonsmoker 

Additional Comments:

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