Car Insurance Quote - Christine Tillett of Washington


Automobile Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

General Information

Name: (required)

E-Mail Address: (required)

Street:

City: (required)

County:

State:(required) Zip: (required)

Day Phone:

Evening Phone:

FAX:

Please list your family's drivers

# First Name Gender Birth Date Married? Social Security #

1

2

3

4

In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information.

Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name

We need to know about your cars.
Please provide the year, make, model & name of daily driver
Answer should look like this : 1998, Ford, Taurus, Mary

All of this information is required to receive a quotation

Veh# Year - Make - Model How is this car used?
Annual Miles

1

2

3

Tell us the current coverages on your cars?

Comprehensive Deductible

Collision Deductible

Bodily Injury Liability Limit (000)

Property Damage Liability Limit

Uninsured Motorist Bodily Injury Liability (000)

Uninsured Motorist Property Damage Liability

Personal Injury Protection

Medical Payments

Road Service Coverage

Rental Car Reimbursement

What month current policy expire?

What is the name current insurance company?

Accidents & Violations

Last 3 Yrs (Minors)
Last 5 Yrs (Majors) Driver 1 Driver 2 Driver 3 Driver 4

Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)

Accidents - Non Chargeable (Within the last 5 years)

Accidents - Chargeable (Within the last 5 years)

Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit (Within the last 5 years)

General Information
Name: (required)
E-Mail Address: (required)
Street:
City: (required)
County:
State:(required)	Zip: (required)
Day Phone:
Evening Phone:
FAX:

Tell us the current coverages on your cars?
Comprehensive Deductible
Collision Deductible
Bodily Injury Liability Limit (000)
Property Damage Liability Limit
Uninsured Motorist Bodily Injury Liability (000)
Uninsured Motorist Property Damage Liability
Personal Injury Protection
Medical Payments
Road Service Coverage
Rental Car Reimbursement
What month current policy expire?
What is the name current insurance company?

The following information is optional, but if given we will be able to provide you with a more accurate premium quotation.

Drivers' Information:

Driver #	License Number (required in California)	Years Licenced (required in California)
1
2
3
4


Vehicle Identification Numbers

Veh #1

Veh #2

Veh #3

Please use this area to give us any additional information that you may feel is important for your insurance. ie: Is one of your cars used to deliver pizzas or conduct another type of business? Do your young drivers have a B average or better in school?

Are there any additional cars or drivers?

**Vehicle Identification Numbers**
Veh #1
Veh #2
Veh #3

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mail to: gkh@InsuranceQuote.net< /ADDRESS>

Page Created 8-13-2004


Latest Revision

#	First Name	Gender	Birth Date	Married?	Social Security #
1
2
3
4

In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information.

Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name

Veh#	Year - Make - Model	How is this car used?	Annual Miles
1
2
3

Accidents & Violations
Last 3 Yrs (Minors) Last 5 Yrs (Majors)	Driver 1	Driver 2	Driver 3	Driver 4
Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)
Accidents - Non Chargeable (Within the last 5 years)
Accidents - Chargeable (Within the last 5 years)
Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit (Within the last 5 years)

General Information

Tell us the current coverages on your cars?

Accidents & Violations