Personal Insurance Quote Form
Personal Insurance Quote Complete the form below to receive the most accurate insurance quote Name : Home Phone : Work Phone: FAX: Address: City: State: Zip: E-Mail address: Best Time to Call: Homeowner Information Type of Residence: house condo apt Construction: wood brick If house, estimated replacement cost: $ year built # of families: 1 2 3 # of stories: garage none attached freestanding Alarms: Burglar Fire # smoke detectors # of smokers in house Estimated Replacement Cost of Contents: $ Deductible : $250 $500 $1000 $1500 $2000 yes no Auto Information Driver Lisc.# : CAR # 1 Year CAR # 2 Year Make Make Model Model Doors Doors Alarm none active passive Alarm none active passive Air Bags none driver both Air Bags none driver both Anti-lock Brakes none 2w 4w Anti-lock Brakes none 2w 4w Use of car CAR #1 pleasure work business # miles to work one way CAR #2 pleasure work business # miles to work one way Driver Information #1 Age male female married single full part driver car # #2 Age male female married single full part driver car # #3 Age male female married single full part driver car # #4 Age male female married single full part driver car # Do any drivers need proof of financial responsibility ( SR- 22 ) driver # Do any youthful drivers qualify for : Defensive driver training good student Accidents Driver # Accidents mo/yr / Violations mo/yr / Points Driver # Accidents mo/yr / Violations mo/yr / Points Driver # Accidents mo/yr / Violations mo/yr / Points Coverage Limits of Liability : Physical Damage : bodily injury: per person $ Collision Deductible: $ per accident $ comprehensive deductible $ property damage $ State No Fault medical payments $ rental reimbursement uninsured motorist B.I. $ towing and labor uninsured motorist P.D. $ Excess Liability Information Umbrella amount : 1 million 2 million 3 million 4 million 5 million Do you own any: rental property watercraft swimming pool dogs
Name : Home Phone : Work Phone: FAX: Address: City: State: Zip: E-Mail address: Best Time to Call:
Type of Residence: house condo apt Construction: wood brick If house, estimated replacement cost: $ year built
# of families: 1 2 3 # of stories: garage none attached freestanding
Alarms: Burglar Fire # smoke detectors # of smokers in house
Estimated Replacement Cost of Contents: $
Deductible : $250 $500 $1000 $1500 $2000 yes no
Driver Lisc.# :
CAR #1 pleasure work business # miles to work one way CAR #2 pleasure work business # miles to work one way
#1 Age male female married single full part driver car # #2 Age male female married single full part driver car # #3 Age male female married single full part driver car # #4 Age male female married single full part driver car #
Do any drivers need proof of financial responsibility ( SR- 22 ) driver # Do any youthful drivers qualify for : Defensive driver training good student
Driver # Accidents mo/yr / Violations mo/yr / Points Driver # Accidents mo/yr / Violations mo/yr / Points Driver # Accidents mo/yr / Violations mo/yr / Points
Umbrella amount : 1 million 2 million 3 million 4 million 5 million Do you own any: rental property watercraft swimming pool dogs
Millennium Alliance Group
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