|
AUTO INSURANCE QUOTE |
||||||||||||
|
Referred
by:______________________________________________ Phone: Hm:______________ Wk:_____________ Cell:______________ Prior Insurance:________________________________________________ Name: Employment & # yrs:____________________________________ Address:__________________________________________________ County:___________________________________________________ Physical address If PO Box:____________________________________ Own/Rent Home: yes/no Insurance: yes/no Mobil home/Stick built Driver #1: Date of Birth:_______ SS#:__________ TDL#:__________ Tickets/Accidents in last 3-5 years:___Date/Amt.Paid/Facts:__________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Driver #2________________________________________________ Name____________________________________________________ DOB: SS#: TDL#:__________________________________________ Tickets/Accidents:__________________________________________ Vehicle #1________________________________________________ Yr/Make/Model:___________________________________________ Vin#:____________________________________________________ Primary Driver:__________________ Usage:_____________________ Vehicle #2________________________________________________ Yr/Make/Model:___________________________________________ Vin#:____________________________________________________ Primary Driver:__________________ Usage:_____________________ Vehicle #3________________________________________________ Yr/Make/Model:___________________________________________ Vin#:____________________________________________________ Primary Driver:__________________ Usage:_____________________ |
||||||||||||
| ~ADDITIONAL NOTES~ | ||||||||||||
| LIABILITY: | 20/40/15 | 25/50/25 | 50/100/50 | 100/300/100 | 250/500/250 | |||||||
|
PIP/MP: |
2500 | 5000 | 10000 | REJECT | ||||||||
| UP/UIM: | 20/40/15 | 25/50/25 | 50/100/50 | 100/300/100 | 250/500/250 | |||||||
| COMP: |
|
|||||||||||
|
COLL: |
200 | 250 | 500 | 1000 | NONE | |||||||
|
TOWING: |
40 | 25 | 120 | NONE | ... | |||||||
|
RENTAL: |
20 | 25 | 30 | 35 | NONE | |||||||
|
all rights reserved - Pierce & Co. Insurance |
||||||||||||