FAST AND EASY AUTO INSURANCE PROPOSAL FOR BUSY PEOPLE

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1

FIRST NAMEFirst Name

LAST NAME

Dateof appointment

Addressyour full name

Apt or Unit # Leave blank if noneyour full name

Cityyour city

STATE

CA

ZIPZIP

PHONECELL PHONE#

Emaila valid email

Email again for Accuracya valid email

Married ?

YesNo

Homeowner ?

YesNo

Currently Insured ?

YesNo

Current Insurance Company name ?your full name

DRIVER(S) SECTION

First Namefirst name driver 1

Last NameLast name driver 1

Sex Driver 1pick one!

SexMaleFemaleNon Binary

Birthdateyour birthdate

Drivers License #License D-1

Age first LicensedAge Lic

Occupation (For Discounts) Driver 1Occ

If Driver 2, Type same info as in above questions.your full name

If Driver 3, Type same info as in above questions.your full name

VEHICLE(S) SECTION

Year, Make, ModelVeh 1

Vehicle ID Number (VIN#)your full name

Odometer Readingyour full name

Year you purchased ityour full name

Annual Miles

Annual Miles Driven0 - 50005001 - 70007001 - 85008501 - 1000010001 - 1200012001 - 1500015001 - 1800018001 +

Policy level Liability Limits

Policy Level Liability & UM PackageBasic 25/50/25 Silver 50/100/50 Gold 100/300/100 Platinum 250/500/250

Comprehensive Deductible

Comprehensive DeductibleNo Coverage500 Deductible750 Deductible1000 Deductible1250 Deductible2500 Deductible

Collision

Collision DeductibleNo Coverage500 Deductible750 Deductible1000 Deductible1250 Deductible2500 Deductible

Supplemental

Supplemental CoveragesNo CoverageTowingRentalGlass Ded WaiverTowing & RentalTowing & GlassRental & GlassTowing, Rental & Glass

If Vehicle 2, Type same info as in above questions.your full name

If Vehicle 3, Type same info as in above questions. If additional vehicles list them here.more details

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OPTIONAL NOTES HEREyour full name

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