QUOTE SHEET

DRIVER NAME: PHONE: MAILING ADDRESS: DATE OF BIRTH: YEARS AT CURRENT ADDRESS: YEARS AT PRIOR ADDRESS: OWN/RENT: CURRENT INSURANCE COMPANY: YEARS WITH CURRENT INS CO: EXP: NONE: LAPSED: MARRIED/SINGLE/DIVORCED/SEPARATED: MONTH AND YEARS FOR YOUR DRIVERS LICENSE: AGE: MALE/FEMALE: AGE LICENSE ISSUED: OCCUPATION: YEARS OF SCHOOLING: VEHICLE #1: YEAR: MAKE: MODEL: ODOMETER: VEHICLE #2: YEAR: MAKE: MODEL: ODOMETER: VEHICLE #3: YEAR: MAKE: MODEL: ODOMETER: TICKETS OR ACCIDENTS IN LAST 5 YEARS? YES / NO: DWI OR RECKLESS DRIVING EVER? YES / NO: LICENSE EVER SUSPENDED OR REVOKED? YES / NO: LIABILITY: 50/100/50 100/300/50 COMP DEDUCTIBLE: 50-100-250-500-1MIL UNINSURED MOTORIST: 50/100/25 100/300/25 COLLISION DEDUCTIBLE: 250-500-1MIL