Auto Insurance Rate Quotation Request

Residence

Own Rent

Name

Residence Address:
Street # of years at residence
Unit #
City State Zip
Is your mailing address the same? Yes
Mailing Address:
Street Unit #
City State Zip

Home phone:
Work phone:
Email:

Current Insurance

Current Insurance Company Name: AIG Allstate AMEX California Eagle California Casualty Cal. State Auto Association Century National Civil Services Employees Colonial Penn Electric Farmers Fireman's Fund Geico Hartford Kemper Liberty Mercury National Alliance National Automobile National General Non Compliance Progressive Prudential Reliance Response Insurance Safeco State Farm Travelers 20th Century USAA Wawanesa Western Pioneer Zurich Other No Current Insurance
Policy Number:
Current Policy Expiration Date (optional):
Total # of Years of Continuous Liability Insurance:

Driver Information

List All Drivers

Driver 1.
Name M F
Marital Status: Married/Widowed Single, Divorced/Separated
Birthdate:
Year First Licensed:

Number of Years Continuously Licensed in California:
Number of Years with Current Employer:
Retired? Yes No

Please enter ALL 'at fault' accidents and any violations that you have received within the last 36 months.

Has driver completed a Mature Driver Training Course? Yes No
Date Completed:

Driver 2.

Driver 3.

Driver 4.

Vehicle Information

Vehicle 1.
Year: Make: Annual Mileage:
Garage Parked ? Yes No
Alarm: Yes No
Airbags: None Driver Passenger Both
Vehicle ID #:
Model: *Please indicate the complete model (e.g. Camry CE, LE or XLE)
Is Vehicle Financed? Y N
If yes, lien or lease? Lien Leased
Vehicle Use: Commute Pleasure Business

Specify Any Special Equipment (select all that apply). With regard to sound equipment, specify only that equipment that is considered upgraded/factory or aftermarket.

None
AM/FM Cassette
AM/FM CD
AM/FM Cassette/CD
AM/FM Only
Tape Deck Only
CD Only
Telephone
Camper/Shell
Van Conversion
2-way Radio / CB
Tool / Utility Body
Winch
Hydraulic Lift - Van
Hydraulic Lift - Pickup
Snowplow

Vehicle 2.

Vehicle 3.

Vehicle 4.

Vehicle Assignment

Driver 1:
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Driver 2:
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Driver 3:
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Driver 4:
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4

Coverages Bodily Injury
15,000/30,000 50,000/100,000 100,000/300,000
250,000/500,000 500,000/1,000,000
Other

Property Damage
10,000 25,000 50,000 100,000 250,000
500,000 Other

Medical Payments
No Coverage 2,000 5,000 25,000

Excess Medical Coverage
Yes

Vehicle 1.
Comprehensive Deductible
100 250 500 750 1,000 2,000 No Coverage
Collision Deductible
100 250 500 750 1,000 2,000 No Coverage
Rental Car Coverage (per day)
20 30 45 No Coverage
Uninsured Collision
Yes No

Vehicle 2.

Vehicle 3.

Vehicle 4.

Uninsured/Underinsured Motorist
15,000/30,000 30,000/60,000 Same as Bodily Injury No Coverage
Other

Coverages and deductibles listed above represent only a sample of those we offer. You may also type in a specific limit, or ask a Sales Agent for additional limits. Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club or by independent insurance carriers whose benefits, features and discounts may vary. CA Dept. of Insurance Lic. #0003259.