AUTO QUOTE FORM
PLEASE FILL IN ALL INFORMATION SO WE CAN PROVIDE YOU WITH THE BEST PRICE.
PERSONAL INFORMATION
| First: | Middle: | Last: | |||
| Email: | Phone: | Fax: | |||
| Street Address: | |||||
| City: | State: |
Zip: |
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Preferred Contact: |
Please Contact: |
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GENERAL INFORMATION
| You must live in Texas or plan to move here: | |
| Do you have Auto Insurance now? | |
If "Yes" How long have you |
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| How many Drivers? | |
| How many Cars? | |
| Do you own a home? | |
If "Yes" Who insures your home? |
BASE COVERAGE SELECTION
| Bodily Injury Liability: | |
| Property Damage Liability: | |
| Uninsured/Underinsured Motorist: | |
| Medical Coverage: | |
| Personal Injury Protection | |
| Auto Death & Dismemberment: |
DRIVER AND AUTO INFORMATION
Complete information for each driver and automobile.
NOTE: First driver must be Head of Household.
FIRST DRIVER INFORMATION
| Age: | ||||
| Sex: | ||||
| Relationship to Head of Household: | ||||
| List all Traffic Citations (Tickets) for the past 5 years: Date / What Citation was for. |
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| List all Accidents where this driver was driving, during the
past 5 years: Date / Facts of Accident. |
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| Safety Courses: Select all that apply. | Definsive Driving |
Drivers Ed |
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Drug/Alcohol Awareness |
Alive@55 |
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| Under age 21, full time student, 10th grade or later with 3.0 (B) grade point average or better: | ||||
FIRST AUTOMOBILE INFORMATION
| How is this auto used? | |
| Annual mileage for this auto: | |
| Year: | |
| Make: ex. Chevrolet, Honda, etc. | |
| Exact Model: ex. Cavalier LS, Accord ES, etc. | |
| Type: | |
| If Van with Customization, enter the Cost Price New of the customization. If Motorcycle, enter engine cc and Cost Price New. If Motorhome, enter Cost Price New and Length. | |
| Vehicle Identification #: | |
| Does auto have 4 Wheel Anti-Lock Brakes: | |
| Passive Restraint System: |
SUPPLEMENTAL COVERAGE SELECTION (AUTO 1)
| Comprehensive - Covers such things as Theft, Hail damage, Fire, Glass Breakage, etc., with a Deductible (What you will pay before insurance pays) Comprehensive Coverage with Deductible: | |
| Collision - Covers when auto collides with something or something collides with auto, with a Deductible (What you will pay before insurance pays) Collision Coverage with Deductible: | |
| Loss of Use: (Rental Coverage) Must have Comprehensive & Collision | |
| Emergency Road Service: Must have Comprehensive & Collision and auto less than 15 years old | |
| Towing Coverage |
COMMENTS
|
Click here only if you do not need to add any more drivers or cars.
SECOND DRIVER INFORMATION
| Age: | ||||
| Sex: | ||||
| Relationship to Head of Household: | ||||
| List all Traffic Citations (Tickets) for the past 5 years: Date / What Citation was for. |
||||
| List all Accidents where this driver was driving, during the
past 5 years: Date / Facts of Accident. |
||||
| Safety Courses: Select all that apply. | Definsive Driving |
Drivers Ed |
||
Drug/Alcohol Awareness |
Alive@55 |
|||
| Under age 21, full time student, 10th grade or later with 3.0 (B) grade point average or better: | ||||
SECOND AUTOMOBILE INFORMATION
| How is this auto used? | |
| Annual mileage for this auto: | |
| Year: | |
| Make: ex. Chevrolet, Honda, etc. | |
| Exact Model: ex. Cavalier LS, Accord ES, etc. | |
| Type: | |
| If Van with Customization, enter the Cost Price New of the customization. If Motorcycle, enter engine cc and Cost Price New. If Motorhome, enter Cost Price New and Length. | |
| Vehicle Identification #: | |
| Does auto have 4 Wheel Anti-Lock Brakes: | |
| Passive Restraint System: |
SUPPLEMENTAL COVERAGE SELECTION (AUTO 2)
| Comprehensive - Covers such things as Theft, Hail damage, Fire, Glass Breakage, etc., with a Deductible (What you will pay before insurance pays) Comprehensive Coverage with Deductible: | |
| Collision - Covers when auto collides with something or something collides with auto, with a Deductible (What you will pay before insurance pays) Collision Coverage with Deductible: | |
| Loss of Use: (Rental Coverage) Must have Comprehensive & Collision | |
| Emergency Road Service: Must have Comprehensive & Collision and auto less than 15 years old | |
| Towing Coverage |
COMMENTS
|
Click here only if you do not need to add any more drivers or cars.
THIRD DRIVER INFORMATION
| Age: | ||||
| Sex: | ||||
| Relationship to Head of Household: | ||||
| List all Traffic Citations (Tickets) for the past 5 years: Date / What Citation was for. |
||||
| List all Accidents where this driver was driving, during the
past 5 years: Date / Facts of Accident. |
||||
| Safety Courses: Select all that apply. | Definsive Driving |
Drivers Ed |
||
Drug/Alcohol Awareness |
Alive@55 |
|||
| Under age 21, full time student, 10th grade or later with 3.0 (B) grade point average or better: | ||||
THIRD AUTOMOBILE INFORMATION
| How is this auto used? | |
| Annual mileage for this auto: | |
| Year: | |
| Make: ex. Chevrolet, Honda, etc. | |
| Exact Model: ex. Cavalier LS, Accord ES, etc. | |
| Type: | |
| If Van with Customization, enter the Cost Price New of the customization. If Motorcycle, enter engine cc and Cost Price New. If Motorhome, enter Cost Price New and Length. | |
| Vehicle Identification #: | |
| Does auto have 4 Wheel Anti-Lock Brakes: | |
| Passive Restraint System: |
SUPPLEMENTAL COVERAGE SELECTION (AUTO 3)
| Comprehensive - Covers such things as Theft, Hail damage, Fire, Glass Breakage, etc., with a Deductible (What you will pay before insurance pays) Comprehensive Coverage with Deductible: | |
| Collision - Covers when auto collides with something or something collides with auto, with a Deductible (What you will pay before insurance pays) Collision Coverage with Deductible: | |
| Loss of Use: (Rental Coverage) Must have Comprehensive & Collision | |
| Emergency Road Service: Must have Comprehensive & Collision and auto less than 15 years old | |
| Towing Coverage |
COMMENTS
|
Click here only if you do not need to add any more drivers or cars.
FOURTH DRIVER INFORMATION
| Age: | ||||
| Sex: | ||||
| Relationship to Head of Household: | ||||
| List all Traffic Citations (Tickets) for the past 5 years: Date / What Citation was for. |
||||
| List all Accidents where this driver was driving, during the
past 5 years: Date / Facts of Accident. |
||||
| Safety Courses: Select all that apply. | Definsive Driving |
Drivers Ed |
||
Drug/Alcohol Awareness |
Alive@55 |
|||
| Under age 21, full time student, 10th grade or later with 3.0 (B) grade point average or better: | ||||
FOURTH AUTOMOBILE INFORMATION
| How is this auto used? | |
| Annual mileage for this auto: | |
| Year: | |
| Make: ex. Chevrolet, Honda, etc. | |
| Exact Model: ex. Cavalier LS, Accord ES, etc. | |
| Type: | |
| If Van with Customization, enter the Cost Price New of the customization. If Motorcycle, enter engine cc and Cost Price New. If Motorhome, enter Cost Price New and Length. | |
| Vehicle Identification #: | |
| Does auto have 4 Wheel Anti-Lock Brakes: | |
| Passive Restraint System: |
SUPPLEMENTAL COVERAGE SELECTION (AUTO 4)
| Comprehensive - Covers such things as Theft, Hail damage, Fire, Glass Breakage, etc., with a Deductible (What you will pay before insurance pays) Comprehensive Coverage with Deductible: | |
| Collision - Covers when auto collides with something or something collides with auto, with a Deductible (What you will pay before insurance pays) Collision Coverage with Deductible: | |
| Loss of Use: (Rental Coverage) Must have Comprehensive & Collision | |
| Emergency Road Service: Must have Comprehensive & Collision and auto less than 15 years old | |
| Towing Coverage |
COMMENTS
|
Click here only if you do not need to add any more drivers or cars.
FIFTH DRIVER INFORMATION
| Age: | ||||
| Sex: | ||||
| Relationship to Head of Household: | ||||
| List all Traffic Citations (Tickets) for the past 5 years: Date / What Citation was for. |
||||
| List all Accidents where this driver was driving, during the
past 5 years: Date / Facts of Accident. |
||||
| Safety Courses: Select all that apply. | Definsive Driving |
Drivers Ed |
||
Drug/Alcohol Awareness |
Alive@55 |
|||
| Under age 21, full time student, 10th grade or later with 3.0 (B) grade point average or better: | ||||
FIFTH AUTOMOBILE INFORMATION
| How is this auto used? | |
| Annual mileage for this auto: | |
| Year: | |
| Make: ex. Chevrolet, Honda, etc. | |
| Exact Model: ex. Cavalier LS, Accord ES, etc. | |
| Type: | |
| If Van with Customization, enter the Cost Price New of the customization. If Motorcycle, enter engine cc and Cost Price New. If Motorhome, enter Cost Price New and Length. | |
| Vehicle Identification #: | |
| Does auto have 4 Wheel Anti-Lock Brakes: | |
| Passive Restraint System: |
SUPPLEMENTAL COVERAGE SELECTION (AUTO 5)
| Comprehensive - Covers such things as Theft, Hail damage, Fire, Glass Breakage, etc., with a Deductible (What you will pay before insurance pays) Comprehensive Coverage with Deductible: | |
| Collision - Covers when auto collides with something or something collides with auto, with a Deductible (What you will pay before insurance pays) Collision Coverage with Deductible: | |
| Loss of Use: (Rental Coverage) Must have Comprehensive & Collision | |
| Emergency Road Service: Must have Comprehensive & Collision and auto less than 15 years old | |
| Towing Coverage |
COMMENTS
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Thank you for your time in completing this questionnaire.
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