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Florida Auto Insurance FAQ
Automobile Insurance Consumer's Guide

AUTO INSURANCE
REQUEST for QUOTE
Garaging Information
 
Name:
 
Street
City
State
Zip
 
Home Phone
Work Phone
 
Fax
 
Email
Mailing Address if different from above:
 
Street
City
State
Zip
 
Driver Information
Driver 1
First Name
Last Name
Gender
 Male Female
Marital Status
Years Licensed
State Licensed
Driver's License Number
Occupation
Date of Birth
 
Social Security #:
 
Driver 2
First Name
Last Name
Gender
 Male Female
Marital Status
Years Licensed
State Licensed
Driver's License Number
Occupation
Date of Birth
 
Social Security #:
 
Driver 3
First Name
Last Name
Gender
 Male Female
Marital Status
Years Licensed
State Licensed
Driver's License Number
Occupation
Date of Birth
 
Social Security #:
 
Driver 4
First Name
Last Name
Gender
 Male Female
Marital Status
Years Licensed
State Licensed
Driver's License Number
Occupation
Date of Birth
 
Social Security #:
Vehicle Information
Vehicle 1
Year
Make
Model
VIN #
Miles per Year
Use of Vehicle
If driven to work, how
many miles one way
Anti-lock brakes
 Yes No
Anti-theft device
 Yes No
Primary Driver
 
Vehicle 2
Year
Make
Model
VIN #
Miles per Year
Use of Vehicle
If driven to work, how
many miles one way
Anti-lock brakes
 Yes No
Anti-theft device
 Yes No
Primary Driver
 
Vehicle 3
Year
Make
Model
VIN #
Miles per Year
Use of Vehicle
If driven to work, how
many miles one way
Anti-lock brakes
 Yes No
Anti-theft device
 Yes No
Primary Driver
 
Vehicle 4
Year
Make
Model
VIN #
Miles per Year
Use of Vehicle
If driven to work, how many miles one way
Anti-lock brakes
   Yes No
Anti-theft device
 Yes No
Primary Driver
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Coverage Information
  Bodily Injury Property Damage
Personal liability
Uninsured Motorist  
Stacking
 Yes No  
Personal Injury Protection $10,000 Florida State Mandatory Coverage  
Medical payment  
Deductible Information
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comp (theft) Deductible
Collision Deductible
Rental Reimbursement      
Towing      
Miscellaneous Information
Current Insurance Company
Expiration date
Current premium
How would you rate your credit?
Questions or comments
If you have a youthful operator with a 3.0 average or better, please indicate name in Comments section

Please Note: Insurance coverage cannot be bound without a written binder from our office.

Additionally, Please Note: Many insurance carriers use information gathered from you and outside sources about your claim, driving and credit history. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.

By filling out this quote you agree to the the above terms.

 

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