date received: csr: request for quotation for … request for...request for quotation for automobile...
TRANSCRIPT
Request for Quotation for Automobile Insurance Information Regarding the Insured
First Name Middle Initial Last name DOB
Marital Status:
Occupation (if retired, notate retired)
Spouse Name Middle Initial Last Name DOB
Marital Status:
Occupation (if retired, notate retired)
Street Address City Township County Zip Code
Home Phone Number Business or Cell phone number E‐mail address
Associations you are a member of: (Credit unions, Alumni etc.) MEA Member? Yes No
Mea Retired Member? Yes No
AARP Member? Yes No
Number of Household Members Do you have medical insurance that covers you in an auto‐related accident? Yes No
Name of Medical Carrier Do you have wage loss benefits? (Short‐term or Long‐Term Disability)
Present Insurance Company for Auto
Expiration Date
Preferred method to receive quote: Mail E ‐mail Fax Phone
Present Insurance Company for Home Expiration Date
Additional Notes:
Information Regarding the Vehicles to be Insured Vehicle Year
(2014) Make (Chevy)
Model (Impala)
Vehicle ID number (1X2243K222110DFK)
Usage (check one)
Number of Miles (3‐10)
1 Commute Pleasure Business
2 Commute Pleasure Business
3 Commute Pleasure Business
4 Commute Pleasure Business
Policy Coverage Desired Current Bodily Injury Liability Limits $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$1 million $1 million/$1 million
Property Damage Liability Limit $50,000 $100,000 $250,000 $300,000 $500,000 $1 million
Uninsured/Underinsured Motorist $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$1 million $1 million/$1 million
Deductibles and Optional Coverage The amount you would be willing to pay if you had a loss
Vehicle 1
Vehicle 2 Vehicle 3 Vehicle 4
Comprehensive (Other than Collision) Pays for damage resulting from such things as fire, falling trees, earthquake, theft, vandalism, animals, hail, wind. Glass coverage falls in this category.
$50 $100 $250 $500 Other $_______
$50 $100 $250 $500 Other $_______
$50 $100 $250 $500 Other $_______
$50 $100 $250 $500 Other $______
Collision Pays to fix your car after an accident Limited—Coverage only if you are less than 50% at fault Broad—Coverage regardless who is at fault, but the deductible only applies if you are at fault Regular—Coverage regardless who is at fault, but the deductible always applies.
Limited Regular Broad $100 $250 $500 $1000 Other $_______
Limited Regular Broad $100 $250 $500 $1000 Other $_______
Limited Regular Broad $100 $250 $500 $1000 Other $_______
Limited Regular Broad $100 $250 $500 $1000 Other $_______
Road Trouble Service $50 $100 $150 Other ______________
$50 $100 $150 Other ______________
$50 $100 $150 Other ______________
$50 $100 $150 Other ______________
Rental Coverage $20/$600 $30/900 $40/1200 Other $_____________
$20/$600 $30/900 $40/1200 Other $_____________
$20/$600 $30/900 $40/1200 Other $____________
$20/$600 $30/900 $40/1200 Other $_____________
Date Received: CSR:
Information Regarding the Drivers/Non‐Drivers in the Household (Please list all household members even if they do not currently drive)
Name of Household Member Drivers License Number (If applicable)
Date of Birth Male or Female
Occupation
Primary Vehicle
Driven Good
Student
Driver Safety Course
Claims, Accidents or Violations (please explain and notate
date, amount and if at fault for past 5 years)
M F
M F
M F
M F
M F
M F