Auto Quote Form
Personal Information
Name:
Address:
Email:
Telephone # :
Fax #:
Best time to call:
Vehicle Information
Year:
2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960
Make:
Model:
Vehicle I.D. #:
Annual Mileage:
Air Bag or electric seatbelt?
yes no
Anti-theft device?
Driver Information
Years of driving experience:
Driver training?
Do all drivers have a Georgia drivers license?
Yes No
Please list all tickets and/or accidents in the last six years, or SDIP step if known:
Please list dates of birth and drivers license #'s for all operators (optional for more accurate quote):
Coverage Options
Part 1 - Body Injury:
$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000
Part 2 - Property Damage:
$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000
Part 3 - Uninsured Motorist:
Part 4 - Property damage:
Part 5- Medical Payments:
none $5,000 $10,000 $15,000 $20,000 $25,000 $50,000 $100,000
Part 6 - Collision (deductible):
no coverage $100 $200 $250 $500 $1,000
Part 7- Comprehensive (deductible):
Part 8 Rental Car Transportation:
no coverage $15/day $450 max. $30 day $900 max.
Part 9 - Towing and Labor:
no coverage $25 per disablement $50 per disablement
Statement that the claimant agrees that all the information submitted in this form is truthful, and that they understand fraudulent claims are illegal and can be prosecuted by law etc etc etc...
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