Class Act Insurance Services

Vehicle

Current Odometer

Was the Car Purchased New?

Ownership Type

Auto Insurance Quote Request
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Reason for insurance request:
New purchase Current owner with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price

Name: First:

Last :

Street Address:

Apt # / Unit:

City: County of:

State:

Zip Code:

Yrs at Current Residence:

Residence is:

Home phone:

Work phone:

Fax :

Email Address:

Occupation:

Yrs Employed:

Prior Insurance Co:

Insurance Expires on:

Yrs w/ Continuous Coverage:

Drivers Information

	Name and Relationship	Drivers Lic.# and State	Sex	Marital Status	Date of Birth	Drives What Vehicle (Yr and Make)	List Percent Vehicle Used (I.E. 65% etc.)
#1
#2
#3
#4

Vehicle Information

Vehicle	Year	Make (Chev, Ford, etc.)	Model (Mustang, Camaro, etc.)	Body (2 door, 4door wagon,etc.)	Vehicle Identification Number (Can be found on your registration)	Car Used for	Miles One Way	Miles Driven Annually
#1
#2
#3
#4

Coverages

Vehicle	Bodily Injury Liability	Uninsured Motorist bodily Injury	Property Damage Liability	Medical Payments Coverage	Collision Deductible	Comprehensive Deductible
#1		Same Coverage as Bodily Injury Liability
#2	Same as above	Same as above	Same as above	Same as above
#3	Same as above	Same as above	Same as above	Same as above
#4	Same as above	Same as above	Same as above	Same as above

Accidents/Violations/Comp Losses (Check Here if None )

Incident Type	Date of Incident	Driver	Incident Description	Damage Amount

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IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.