Auto Insurance Quote Form

This is a request for a quotation for automobile insurance. It is not an application for insurance.
To expedite your quote, please provide the following information.
Name:
 Education Level:
Spouse's Name:
Business Phone:
Street:
Home Phone
City:
 E-Mail:
State:
    
Zip Code:
 Are you an Amercian Greetings
Credit Union member?		 No: Yes
CURRENT POLICY INFORMATION
  Insurance Company: Policy Liability Limit $:
 
Annual Premium $:
Expiration Date:
DRIVER INFORMATION
 
Do You:
Own a home/condo? Own a mobile home? Rent/other?
    Have you, or any driver in the household had their license suspended or revoked in the past five years?
If yes, please expain:
  Yes No
 
List all licensed drivers in your household
  Driver
Name:		 DOB
/Age
(00/00/0000)		 Sex
(M/F):		 Marital
Status:		 Age Licensed: Away at
School?		 Driver
Training?		 A/B Grade
Point Avg?
1.
2.
3.
4.
5.
6.
List Accident (even if someone else was at-fault) / Convictions /Claims
(include any fire, theft, glass or vandalism claims) in the past five years.
  Driver Name: Date: Accident/
Conviction/
Claim
Description:		 Any bodily injury or deaths? Payout amount:
1.
2.
3.
4.
5.
6.
Any accidents
/convictions/claims from the same incident?		    
Has any driver been uninsured for more than 30 days?    
VEHICLE INFORMATION
  Year: Make/Model: Vehicle ID #: Safety Devices: Annual Miles: Commute miles (to work/school): Any business use other than commute? Does the vehicle have a lienholder?
1
2
3
4
Are all vehicles garaged at your address? Does any vehicle have an alarm or anti-theft device?

Is any vehicle equipped with racing or speed acceleration equipment?
Yes No Yes No Yes No

 

 Is any auto for which a quote is being requested titled or registered other than the person named above?  
  Yes No

 

 If "yes," provide the name of the title holder /registrant below.
 
VEHICLE USAGE:
  Driver Name: License #: State:
vehicle 1
% of usage:


vehicle 2
% of usage:
vehicle 3
% of usage:
vehicle 4
% of usage:
1
2
3
4
5
6

 

Remarks:
 
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