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Auto Insurance Quote Form
Please fill out the information requested below.  All information is confidential.

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Driver #1
     
First Name Last:
Address
City
Zip State:
Daytime Phone
Fax
Email
      
Date of Birth: 
Social Sucurity #:
Sex:
Marital status:
Years Licensed: in the US 
in another country
Occupation
     
Car #1
Year / Make
Model  Be precise
Vehicle ID#  (VIN)
Mileage on car
Distance to work
Yes No is this leased vehicle ?

Safety Features:

 Air Bag
Air bags
Anti-Lock Brakes
Alarm
Daytime Run Lights
Seat Belts
   
Coverage 
Bodily Injury / Property Damage
Medical Payments
Uninsured Motorist
Comprehensive
Collision
TowingService: only with comprehensive and collision
Rental Reimbursement: only with comprehensive and collision
 Adress for this vehicle:
Same as Driver #1
Other (Specify below)
Are you interested in any other type of insurance?
Home
Flood
Boat
Motorcycle
Business Auto 		Umbrella
Life
Long Term Care
Disability
Business
 
Remarks:
    
Within the past 5 years have you been involved in an accident, had a traffic violation, suspended or expired license, or made any claim on auto insurance? If so, please describe briefly when?, injuries ?
Current Insurance Company
Date Coverage Expires
     
Driver 2
     
First Name Last:
Relationship to Applicant
Date of Birth: 
Social Security #:
Sex:
Marital status:
Years Licensed : in the US 
in another country
Occupation
   
Driver 3
     
First Name Last:
Relationship to Applicant
Date of Birth: 
Social Security #:
Sex:
Marital status:
Years Licensed : in the US 
in another country
Occupation
   
Driver 4
     
First Name Last:
Relationship to Applicant
Date of Birth: 
Social Security #:
Sex:
Marital status:
Years Licensed : in the US 
in another country
Occupation
   
Car #2
Year / Make
Model  Be precise
Vehicle ID#  (VIN)
Mileage on car
Distance to work
Yes No is this leased vehicle ?

Safety Features:

 Air Bag
Air bags
Anti-Lock Brakes
Alarm
Daytime Run Lights
Seat Belts
   
Coverage 
Bodily Injury / Property Damage
Medical Payments
Uninsured Motorist
Comprehensive
Collision
TowingService: only with comprehensive and collision
Rental Reimbursement: only with comprehensive and collision
 Adress for this vehicle:
Same as Driver #1
Other (Specify below)
   
Car #3
Year / Make
Model  Be precise
Vehicle ID#  (VIN)
Mileage on car
Distance to work
Yes No is this leased vehicle ?

Safety Features:

 Air Bag
Air bags
Anti-Lock Brakes
Alarm
Daytime Run Lights
Seat Belts
   
Coverage 
Bodily Injury / Property Damage
Medical Payments
Uninsured Motorist
Comprehensive
Collision
   
Car #4
Year / Make
Model  Be precise
Vehicle ID#  (VIN)
Mileage on car
Distance to work
Yes No is this leased vehicle ?

Safety Features:

 Air Bag
Air bags
Anti-Lock Brakes
Alarm
Daytime Run Lights
Seat Belts
     
Coverage 
Bodily Injury / Property Damage
Medical Payments
Uninsured Motorist
Comprehensive
Collision
     
 
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All Lines Insurance

Jack Miller, CLU, CPIA
Donna Adelkopf CIC, CPIA

1290 Weston Road, Suite 200

Fort Lauderdale, FL 33326

Phone: (954) 384-6100, Fax: (954) 384-6133

Info@all-lines-ins.com

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