SCW Agency

Auto Insurance

Automobile Insurance

AUTOMOBILE INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only.

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information

First Name
Last Name
E-Mail Address
Daytime Phone Number
Evening Phone Number
Fax Number
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address
City
State
Zip code
Do you currently own your home, or rent?	Own Rent
Driver's license number
Social security number

Driver Information

Driver	Name	Relationship to applicant	Sex	Marital status	Driver's age	Which vehicle does he/she drive?	Percent use
#1			Male Female	Married Single
#2			Male Female	Married Single
#3			Male Female	Married Single
#4			Male Female	Married Single

Driver History

Currently insured with (company name not agency)
Have you or any other driver in your household:
Had a ticket in the last 3 years?	Yes No
Had a license suspended or revoked in the last 6 years?	Yes No
Had a financial responsibility filing in the last 6 years?	Yes No
Made any claims in the last 5 years?	Yes No
If you answered yes to any of the above questions, please explain:

Vehicle #1 Information

Year	Make	Model	Vehicle ID# (VIN)

Primary driver
Annual mileage
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address City State Zip

Vehicle #2 Information

Year	Make	Model	Vehicle ID# (VIN)

Primary driver
Annual mileage
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address City State Zip

Vehicle #3 Information

Year	Make	Model	Vehicle ID# (VIN)

Primary driver
Annual mileage
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address City State Zip

Vehicle #4 Information

Year	Make	Model	Vehicle ID# (VIN)

Primary driver
Annual mileage
Is the vehicle driven to school or work?	Yes No
If driven to school or work, how many weeks per month?	Days Weeks
If driven to school or work, how many miles one way?	Miles
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address City State Zip

Coverage Options

Bodily injury liability
Property damage liability
Underinsured motorist-bodily injury
Underinsured motorist-property damage
Medical-personal injury protection
Accidental death

Coverage Deductibles

	Comprehensive	Collision	Towing coverage
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4