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"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             


Tell Us About ALL the Drivers Living in Your Household:

Indicate every person who resides with you!






Date of Birth

Drivers License Number and the State

Driver Three:
Driver Four:

Tell Us About Your Driving Distances:


Miles to work

Miles to school

Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

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:


Who Handles Your Home Insurance?
Current Auto Insurer:
How do You Like to Pay?
Next Payment Due:

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.


This agency is licensed only in California. Company links or logos on this web site does not imply the endorsement by those companies of this web site. This is an "agency only" site. Please note that we cannot bind coverage through our web site or through email. For more information regarding bound coverage, please call us.

Copyright 2005 www.davidcookinsurance.com