Auto/Motorcycle Quote Form
Please
fill out as much information as possible. If you have any questions
about this form or filing a claim, please contact
us.
|
| PERSONAL
INFORMATION |
| Name: |
|
| Street
Address: |
|
| City,
State, Zip Code: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| |
|
| AUTO
/ MOTORCYCLE INFORMATION |
|
#1 Year:
|
Make:
|
Model:
|
Coverage:
|
| #2 Year:
|
Make:
|
Model:
|
Coverage: |
| #3 Year:
|
Make:
|
Model:
|
Coverage: |
| #4 Year:
|
Make:
|
Model:
|
Coverage: |
|
* Horsepower only if motorcycle. HP*:
|
| |
|
| DRIVER INFORMATION |
Name:
DOB:
|
DL
#:
Car
Driven:
Usage:
|
Name:
DOB:
|
DL
#:
Car
Driven:
Usage:
|
Name:
DOB:
|
DL
#:
Car
Driven:
Usage:
|
Name:
DOB:
|
DL
#:
Car
Driven:
Usage:
|
Have
any of the above drivers had any tickets or accidents in the last
three years?
Yes
No |
| If
yes, please
list all tickets and/or accidents in the last three years, including
dates: |
|
| Bodily
Injury to others: |
|
| Property
damage: |
|
| Uninsured
Motorist: |
|
| Medical
Payments: |
|
| Collision
(deductible): |
|
| Comprehensive
(deductible): |
|
| Substitute
Transportation: |
|
| Towing
and Labor: |
|
| |
|
| UMBRELLA
POLICY (OPTIONAL) |
| Are
you interested in a Umbrella Policy?
Yes
No |
| If
yes, complete the following: |
| #
of cars: |
|
| #
of boats: |
|
| #
of houses: |
|
| #
of drivers in the household: |
|
| Umbrella
Limit: |
|
| |
|
|
|
|
| Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
