AUTO INSURANCE PROPOSAL REQUEST

"We Look for EVERY WAY to Save Money, and Not Sacrifice Important Coverages!"                                                                                     - David Cook, LUTCF, NP   First, Tell Us a Little About You:
Name (required)
E-mail (required)
Telephone (required)
Address (required)
City (required)
State (required)
Zip (required)

Tell Us About Your Vehicles:

	Year, Make, and Model:	Garaging zip code: (Required)
Vehicle #1:
Vehicle #2:
Vehicle #3:
Vehicle #4:

 

Tell Us About the Coverage You Desire (If Known):

Bodily Injury
Property Damage
Uninsured Motorist
Medical Coverage
Trailers? Other Special Needs?
	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Comprehensive Deductible
Collision Deductible
Car Rental
Towing

 

Tell Us About ALL the Drivers Living in Your Household:

Indicate every person who resides with you!

	Gender	Married	Date of Birth			Drivers License Number and the State
Primary:	Select Male Female	Select Married Single	Mth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	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 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932
Spouse:	Select Male Female	Select Married Single	Mth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	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 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932
Driver Three:	Select Male Female	Select Married Single	Mth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	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 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932
Driver Four:	Select Male Female	Select Married Single	Mth Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	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 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932

Tell Us About Your Driving Distances:

	Driver	Miles to work	Miles to school
Vehicle #1	You Spouse Driver3 Driver4
Vehicle #2	Select You Spouse Driver3 Driver4
Vehicle #3	Select You Spouse Driver3 Driver4
Vehicle #4	Select You Spouse Driver3 Driver4

How is Your Driving Record?

List all convictions for minor traffic tickets and all Negligent Accidents*  for the LAST SIX YEARS.

List all DUI's for the last seven years.  This Will be Kept Confidential. 

 

*Note: We Consider a "Negligent Accident" one where you are 51% or more at fault, AND

the damage was OVER $750.00. 

 

Driver	List your Tickets in last 6 years, and the dates they occurred:	List "Negligent Accidents" over $750 in last six years and the date(s):	DUI's in the last 7 years, and the conviction date:
You
Select Spouse Driver3 Driver4
Select Spouse Driver3 Driver4
Select Spouse Driver3 Driver4

 

Who Handles Your Home Insurance?
Current Auto Insurer:
How do You Like to Pay?	Monthly Quarterly Semi Annual Annual
Next Payment Due:	Please Select Very Soon Soon In a few weeks In a few months Other

Business and Professional Group Discounts!

See our List at the Bottom of This Page.  Do You Belong to any group?   If so, DISCOUNTS RANGING FROM 10-15% WILL BE APPLIED TO EVERY CAR IN YOUR HOUSEHOLD! 

Please Indicate Your Business and Professional Group in the Box Below.  You can also make any Additional Comments, Questions, Concerns, Additional Drivers, Cars, etc. in the Same Box . 

Thank You!

Rest assured we will not share this information with anyone.  It will only be used to help you secure a low cost auto insurance proposal from our agency.  Be sure to verify your e-mail address, and phone number so we can contact you.  Otherwise we cannot complete your request.  We are a professional organization with over 20 years experience, and licensed staff.  We respect your right to privacy and honor this trust.

ELIGIBLE BUSINESS AND PROFESSIONAL GROUPS (documentation will be  required to obtain these discounts):  Accountants, Architects, Aviation Professionals, Dentists, Educators, Teachers, Principals, Superintendents, Licensed or Degreed Engineers, FIG Federal Credit Union members, Firefighters (city, county, state, or federal), Lawyers, Judges, Librarians, Physical or Occupational Therapists, Physicians, Surgeons, Badge-Holding Law Enforcement or Peace Officers (city, county, state, or federal), Probation Officers, Real Estate Agents, Registered Nurses, "Scientists" (with verification of Bachelors, Masters, or PhD degree in the field of actuarial science, biochemistry, astronomy, biology, chemistry, computer science, computer graphics, computer information, computer applications, computer programming, computer technology, cybernetics, ecology, genetics, geology, geophysics, mathematics, meteorology, neuroscience, physics, physiology, oceanography, planetary systems, or statistics), Business Owners or Corporate Officers who have their business policy OR workers compensation insurance policy with Farmers Insurance Group, Speech Audiologists, Pathologists, Veterinarians, and Retirees of an Eligible Affinity Group above.

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