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You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.


Personal Information

Name Email Address
Address Day Phone
City Night Phone
State  Zip  Best Time to Call   AM   PM
Preferred Contact Method Email   Phone


Current Auto Insurance Information

Company Name Policy Expiration
Premium Amount Term
Are You A Homeowner? Y  N Insurance
Carrier


Vehicle Information (include all cars you or your family members own or lease)

Car #1
Year
Make
Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Milage
Drive to school/work?
# of miles
(one way)
  Airbags  
Car Alarm
Y N
Y  N
Y  N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:
Driver Name


Car #2 (enter info)

Car #3 (enter info)

Car #4 (enter info)


Liability Limit for ALL Cars

Choose either   Bodily Injury   and   Property Damage
or   Single Limit
Bodily Injury
        
Property Damage
Single Limit

The minimum auto liability coverage amount required by the states of Texas and Arkansas is $30,000 for each injured person, up to a total of $60,000 per accident, and $25,000 for property damage.


Other Coverages

Personal Injury Protection/Medical Payments
Uninsured/Underinsured Motorist - Bodily Injury
Uninsured/Underinsured Motorist - Property Damage

Texas and Arkansas insurers must offer you $2,500 in Personal Injury Protection, but you can buy more. Texas and Arkansas require insurance applicants to reject PIP coverage in writing if they don't want it.


Deductibles and Misc.

Car#
Comprehensive Deductible
Collision Deductible
Towing
Rental Reimbursement
1
Yes
Yes
2
Yes
Yes
3
Yes
Yes
4
Yes
Yes



Driver Information (include all licensed drivers in your household)

Driver #1
Driver's Name
Drivers License Information
DL#: State: Yr's Licensed:
Relation
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married Single
Drivers Ed: 
Defensive Driving;
Drug & Alcohol Awareness: 
Driver's SSN


Driver #2 (enter info)

Driver #3 (enter info)

Driver #4 (enter info)


Driver History

List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver
Date
Type of Conviction
Speed Over Limit
mph
mph
mph
mph


List ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  


List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Injuries
At Fault
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes



Additional Comments


Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.


1st Class Insurance Services, LLC dba Cathy Boyd's Insurance Agency Insurance

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1st Class Insurance Services, LLC dba Cathy Boyd's Insurance Agency : Serving the personal & business insurance needs of Central Florida since 1998. Providing Insurance Services from Haines City, Florida