Fred Simmons Insurance


AUTO INSURANCE QUOTE FORM

First Name MI Last Name

Physical Address
City State
Mailing Address
City State
Home Phone
Work Phone
Email (required)
Present Auto Insurance Carrier (enter 'none' if no present carrier)
Renewal Date
Do you own your own home? yes      no
Occupation Spouse Occupation

Vehicle #1
Year Make Model
2 dr     4 dr    Miles to work      Annual Mileage
VIN

Vehicle #2
Year Make Model
2 dr     4 dr    Miles to work      Annual Mileage
VIN

Vehicle #3
Year Make Model
2 dr     4 dr    Miles to work      Annual Mileage
VIN

Vehicle #4
Year Make Model
2 dr     4 dr    Miles to work      Annual Mileage
VIN

DRIVER INFO:

Driver #1
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Driver#2
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Driver#3
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Driver#4
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Liability Limit for All Cars
Choose Bodily Injury & Property Damage
Bodily Injury Property Damage
15,000/30,000 5,000
25,000/50,000 25,000
50,000/100,000 50,000
100,000/300,000 100,000
500,000/500,000 500,000
Levels of current Uninsured Motorist coverage

Car #1
Deductible Comprehensive 100 250 500 750 1000
Deductible Collision 250 500 750 1,000  
Tow Yes No  
Rental Reimbursement Yes No  

Car #2
Deductible Comprehensive 100 250 500 750 1000
Deductible Collision 250 500 750 1,000  
Tow Yes No  
Rental Reimbursement Yes No  

Car #3
Deductible Comprehensive 100 250 500 750 1000
Deductible Collision 250 500 750 1,000  
Tow Yes No  
Rental Reimbursement Yes No  

Car #4
Deductible Comprehensive 100 250 500 750 1000
Deductible Collision 250 500 750 1,000  
Tow Yes No  
Rental Reimbursement Yes No  

Comments:
CA License #OC17932

Privacy notice:
Fred Simmons Insurance Marketing, Inc. insures your privacy. We will include a copy of our Privacy Statement upon request.

This conditional quote is based on the the information you provide(d), and is subject to final approval by the carriers' underwriters.


Fred Simmons Insurance, Inc.
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