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Auto Insurance

How Did You Find Us?

1. How Did You Find This Site? Google Yahoo SEVRAR Other (required)
2. If Other, Where?

Your Personal Data

1. Your Name(required)
2. Street Address(required)
3. City, State, & Zip Code
4. E-Mail(valid email required)
5. E-Mail (Again)(valid email required)
6. Phone
7. Fax (Optional)
8. Marital Status Married Single
9. Homeowner Yes No
10. Currently Insured?(If Yes, List Carrier & # of years continuous)

Driver #1 Information

1. Name
2. Birthdate
3. Sex Male Female
4. Accidents in Last 3 years. Be specific to tell if accidents are "at-fault" or "not-at-fault" - Carriers require proof for Not-at-fault accidents
5. At-Fault Accidents 0 1 2 3 4 5 or more
6. Not-At-Fault Accidents 0 1 2 3 4 5 or more
7. Violations in Last 3 years.
8. Number of MINOR Traffic Violations 0 1 2 3 4 5 or more
9. Number of MAJOR Traffic Violations 0 1 2 3 4 5 or more
10. Require SR22? No Yes

Driver #2 Information

1. Name
2. Birthdate
3. Sex Male Female
4. Accidents in Last 3 years.
5. At-Fault Accidents 0 1 2 3 4 5 or More
6. Not-At-Fault Accidents 0 1 2 3 4 5 or more
7. Violations in Last 3 years.
8. Number of MINOR Traffic Violations 0 1 2 3 4 5 or more
9. Number of MAJOR Traffic Violations 0 1 2 3 4 5 or more
10. Require SR22? No Yes
11. If more than 2 drivers, list additional driver's Names, Birthdates, and Driving record history

Vehicle #1 Information

1. Vehicle Year
2. Vehicle Make & Model
3. Vehicle ID Number (If avail.)
4. Annual Miilage

Vehicle #1 Coverage

1. Liability Limits 250,000/500,000BI 100,000PD 100,000/300,000BI 100,000PD 50,000/100,000BI 50,000PD
2. Uninsured/ Underinsured Motorist 250,000/500,000 100,000/300,000 50,000/100,000
3. Medical Payments 1,000 2,500 5,000 10,000 25,000 50,000 No Coverage
4. Collision Deductible 1,000 500 250 No Coverage
5. Comprehensive Deductible 1,000 500 250
6. Full Glass Coverage? Yes No
7. Rental Car & Towing Coverage? Yes No

Vehicle #2 Information

1. Vehicle Year
2. Vehicle Make & Model
3. Vehicle ID Number (If avail.)
4. Annual Milage

Vehicle #2 Coverage

1. Liability Limits Must Match Vehicle #1
2. Uninsured/Underinsured Limits Must Match Vehicle #1
3. Medical Payments Must Match Vehicle #1
4. Collision Deductible 1,000 500 250 No Coverage
5. Comprehensive Deductible 1,000 500 250 No Coverage
6. Full Glass Coverage? Yes No
7. Rental Car & Towing Coverage? Yes No

Comments or Remarks

1. If more than 2 vehicles, list additional vehicle's year, make, model, VIN, milage
2. List any additional comments or questions

How Should We Contact You?

1. Send My Quote Via E-Mail Fax Regular Mail Please Call Me!
2. We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes.
3. By answering the box below and clicking the "Quote Me" button you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
4. What color is snow?

 

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Copyright © 2007-2008 · Fox Insurance Services, LLC · (480) 699-7222 · (866) 581-9503
4824 E. Baseline Rd. Ste. 101, Mesa, AZ 85206

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