A.D. DERN INSURANCE AGENCY, INC.

AUTO, RV, MOTORCYCLE, & WATERCRAFT

INSURANCE QUOTE FORM

CUSTOMER INFORMATION *required fields in red

    
*Email Address
*Home Telephone
*Applicant's First Name
Cell Telephone

Mailing Address

Business Telephone
City State Zip County
Fax Telephone

Residence type (check one) Condo-owned Rented Home/Condo/Apartment Other
Number of years/months at current address . . . .
Prior Address
Current Auto Insurance Carrier Policy Number Renewal Date (mm/dd/yr)

DRIVER / OPERATOR INFORMATION - See Privacy Statement
 

Name

SS #
(no spaces)
DOB
(mm/dd/year)
Gender
M/F
Marital
Status
DL # & State
Year 1st Licensed

Need SR22
License Suspended in the past 5 years?
1
2
3
4
# of children in the household yes no
Driver
Occupation
Employer Name
Business Type
Years / Mos with current employer
Previous occupation (if less than 2 years)

Years / Mos in previous occupation

1
2
/
/
3
/
/
4
/
/

VEHICLE DETAIL

V E H
Year
Make
Model
VIN # (required)
% each driver uses vehicle

Anti-theft
Y/N
Anti-lock brakes
Y/N
Drive to work or school?
Miles 1-Way
Annual miles
Vehicle Type
Driver 1
Driver 2
Driver 3
Driver 4
1
2
3
4

List Values of Vehicles Here . . . . . . . . . . . . . . . . . .

If Boat or Jet Ski, what is Engine Horse Power?

If MotorCycle or ATV, what is Engine CC's?

Does any vehicle have existing damage? If Yes, Please list & describe
Are any autos used for business, farm, or pizza delivery purposes? yes no If Yes, Please list & describe
Are any vehicles garaged at a different location? yes no If Yes, please give address


ACCIDENTS / VIOLATIONS
Driver
# of at-fault accidents
# of not at-fault accidents
# of traffic violations
Type of accident or violation?

Date of accident or violation

City of accident or violation
At-fault?
(Y/N)
Vehicle involved

Bodily Injury or death

Amount of claim paid
1
2
3
4

Any driver been canceled or non-renewed in past 5 yrs? yes no If yes, please explain


INSURANCE COVERAGE

LIABILITY COVERAGE
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist
Uninsured Motorist Property Damage

PHYSICAL DAMAGE COVERAGE        
 
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Comprehensive Less Deductible
Collision Less Deductible
Waiver of Collision Ded for UM 
Rental Reimbursement
Towing

 

ADDITIONAL NOTES - Driving Records, License Suspension, SR-22, Claims

 

I/We acknowledge submission of this information is to receive a price quote for insurance, and that NO INSURANCE IS INFORCE until a completed and signed application with payment has been accepted by A.D. Dern Insurance Agency, Inc. and according to any specific Insurance Company requirements.

I agree to the above terms