Wiglesworth - Rindom Insurance Agency

AUTOMOBILE INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name:

Last Name:

E-mail address:

Daytime Phone Number:

Evening Phone Number:

Fax Number:

How would you prefer to be contacted regarding your quote?

Phone Fax Mail E-mail

If you would prefer to be contacted by phone, please let us know the best time to call.

AM PM

Address:

City:

State:

Zip code:

Do you currently own your home, or rent?

Own Rent

Driver's license number:

Social Security number:

DRIVER INFORMATION

DRIVER #1
Name:
Relationship to applicant:
Sex:	Male Female
Marital status:	Married Single
Driver's age:
Which vehicle does he/she drive?
Percent use:

DRIVER #2
Name:
Relationship to applicant:
Sex:	Male Female
Marital status:	Married Single
Driver's age:
Which vehicle does he/she drive?
Percent use:

DRIVER #3
Name:
Relationship to applicant:
Sex:	Male Female
Marital status:	Married Single
Driver's age:
Which vehicle does he/she drive?
Percent use:

DRIVER #4
Name:
Relationship to applicant:
Sex:	Male Female
Marital status:	Married Single
Driver's age:
Which vehicle does he/she drive?
Percent use:

DRIVER HISTORY

Currently insured with (company name not agency):

Have you or any other driver in your household:

Had a ticket in the last 3 years?

Yes No

Had a license suspended or revoked in the last 6 years?

Yes No

Had a financial responsibility filing in the last 6 years?

Yes No

Made any claims in the last 5 years?

Yes No

If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

VEHICLE #2 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

VEHICLE #3 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

VEHICLE #4 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

COVERAGE OPTIONS

Bodily injury liability:

Property damage liability:

Underinsured motorist-bodily injury:

Underinsured motorist-property damage:

Medical-personal injury protection:

Accidental death:

COVERAGE DEDUCTIBLES

	Comprehensive deductible:	Collision deductible:	Towing coverage deductible:
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

QUOTATION FORMS
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