Online Auto Quick Quote Form Name: Street Address: City: State (MUST BE  IN CA) Zip Code: E-Mail (Required): RE-Enter E-Mail: Home Phone: Alternate Phone: Fax (optional): Marital Status: Single Married Homeowner? Yes No Currently Insured? If yes, please list carrier, and # of years with them. If none, type N/A ---------------------------------------------------------------------------------------------------------------- Driver Information #1 Birthdate: Name: Number of years licensed in the US: Sex (M/F): Please specifically state if the accidents are 'at-fault' or 'not at-fault' (most carriers require proof of accidents that are not at fault. Also, please be specific as to the type of violations and approximately when they occurred as it will assist us in giving you the best quote possible. Number & types of accidents in last 3 years Number & types of MINOR CITES in last 3 years Number & types of MAJOR CITES in last 3 years Daily commute in ONE WAY miles Does Driver Need Special Filings? Yes No If YES to filings, why needed? ---------------------------------------------------------------------------------------------------------------- Driver Information #2 (if none leave blank) Birthdate: Name: Number of years licensed in the US: Sex (M/F): Please specifically state if the accidents are 'at-fault' or 'not at-fault' (most carriers require proof of accidents that are not at fault. Also, please be specific as to the type of violations and approximately when they occurred as it will assist us in giving you the best quote possible. Number & types of accidents in last 3 years Number & types of MINOR CITES in last 3 years Number & types of MAJOR CITES in last 3 years Daily commute in ONE WAY miles Does Driver Need Special Filings? Yes No If YES to filings, why needed? ---------------------------------------------------------------------------------------------------------------- Vehicle #1 Information Make & Model Year of Vehicle Annual Mileage Used for Business? If yes, please explain Vehicle #1 Coverages $15/30 Bodily Injury / 10 Property Damage Limits of Liability: (Choose one) $50/100 Bodily Injury / 50 Property Damage $100/300 Bodily Injury / 50 Property Damage $250/500 Bodily Injury / 100 Property Damage $100 Deductible Comprehensive and Collision: (Choose one) $250 Deductible $500 Deductible $1000 Deductible Do you want uninsured motorist? Yes No Do you want medical coverage? Yes No ---------------------------------------------------------------------------------------------------------------- Vehicle #2 Information (if none leave blank) Make & Model Year of Vehicle Annual Mileage Used for Business? If yes, please explain Vehicle #2 Coverages $15/30 Bodily Injury / 10 Property Damage Limits of Liability: (Choose one) $50/100 Bodily Injury / 50 Property Damage $100/300 Bodily Injury / 50 Property Damage $250/500 Bodily Injury / 100 Property Damage $100 Deductible Comprehensive and Collision: (Choose one) $250 Deductible $500 Deductible $1000 Deductible Do you want uninsured motorist? Yes No Do you want medical coverage? Yes No Additional Comments or Questions Please use this area to let us know any other information not covered in this quote form. (ex. Were you referred by anyone, additional drivers, additional vehicles?) ---------------------------------------------------------------------------------------------------------------- Thank you for filling out this form! We will call you back with a quick quote as soon as we input all your information. We value your input as CONFIDENTIAL information. We take every possible step to ensure your privacy and security and that we release your quote information only to you. We will not give your information to ANY other person or group for sales, marketing, or any other purpose. By checking the box below you agree to allow our agency to view your information and obtain a quote for you. Our intention is to maintain confidentiality with your information. Yes, I Agree, Please send me an Auto Quote Now! Click the Button Below When Done