Auto Insurance Quote Form

Name
Street
City
State Zip Code
E-Mail Address

Telephone Number

Social Security Number

Current Carrier Information

Who is your current insurance carrier (not agency)?
Insurance carrier name:

What is the expiration date of your current automobile policy?
Expiration date:

Vehicle Description

Vehicle #1 (Year, Make & Model)
Vehicle #2 (Year, Make & Model)
Vehicle #3 (Year, Make & Model)
Vehicle #4 (Year, Make & Model)

VIN #

VIN#1 (Vehicle Identification Number)
VIN #2 (Vehicle Identification Number)
VIN #3 (Vehicle Identification Number)
VIN #4 (Vehicle Identification Number)

Vehicle Use

Vehicle #1 Pleasure Driven to work - 3-15 miles one way Driven to work - 15 miles or more one way Business Use
Vehicle #2 Pleasure Driven to work - 3-15 miles one way Driven to work - 15 miles or more one way Business Use
Vehicle #3 Pleasure Driven to work - 3-15 miles one way Driven to work - 15 miles or more one way Business Use
Vehicle #4 Pleasure Driven to work - 3-15 miles one way Driven to work - 15 miles or more one way Business Use

Driver Information

Driver #1

Driver Name Date of Birth   Gender Male Female

Marital Status Single Married

Driver's Social Security #

Residence Type Own Home Live with Parents Rent

Education High School Associate Degree Bachelor Degree Master Degree

Driver's License # (Required)

Which car do you drive?

Please enter any tickets  last 3 years :

Please enter any accidents last 5 years, date of accident and $ amount paid::

Driver #2

Driver Name Date of Birth   Gender Male Female

Marital Status Single Married

Driver's Social Security #

Residence Type Own Home Live with Parents Rent

Education High School Associate Degree Bachelor Degree Master Degree

Driver's License # (Required)

Which car do you drive?

Please enter any tickets  last 3 years :

Please enter any accidents last 5 years, date of accident and $ amount paid::

Driver #3

Driver Name Date of Birth   Gender Male Female

Marital Status Single Married

Driver's Social Security #

Residence Type Own Home Live with Parents Rent

Education High School Associate Degree Bachelor Degree Master Degree

Driver's License # (Required)

Which car do you drive?

Please enter any tickets  last 3 years :

Please enter any accidents last 5 years, date of accident and $ amount paid::

Coverage's

Liability Coverage and Limits

$25,000/person,$50,000/accident, $25,000 property damage $50,000/person, $100,000/accident, $ 50,000 property damage $100,000/person, $300,000/accident, $100,000 property damage $250,000/person, $500,000/accident, $100,000 property damage $100,000 Combined Single Limit $300,000 Combined Single Limit $500,000 Combined Single Limit

Uninsured/Underinsured Motorist coverage's

$25,000/person, $50,000/accident $50,000/person, $ 100,000/accident $100,000/person, $ 300,000/accident $250,000/person, $ 500,000/accident $100,000 Combined Single Limit $300,000 Combined Single Limit $ 500,000 Combined Single Limit

Uninsured Motorist /Property Damage

$ 10,000/accident $25.000/accident $50,000/accident

Comprehensive/Other Than Collision

Deductible Vehicle #1 $ 50.00 $100 $200 $500
Deductible Vehicle #2 $ 50.00 $100 $200 $500
Deductible Vehicle #3 $ 50.00 $100 $200 $500
Deductible Vehicle #4 $ 50.00 $100 $200 $500

Collision

Deductible Vehicle #1 $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible
Deductible Vehicle #2 $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible
Deductible Vehicle #3 $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible
Deductible Vehicle #4 $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible

Towing Coverage Yes No
Rental Reimbursement Coverage Yes No

How would you like us to respond Phone E-Mail Fax US Post Office

Please enter any questions or comments :

 ****To provide a quote with Jones, Kendall, Sauer Inc. the insurance company’s will use information, such as driving record, claims, and credit history, from consumer reporting agencies. ****