Auto Insurance
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AUTO INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on an Auto insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
This quote is for small to medium size vehicles, vans, pick-up trucks, four wheel drives and station wagons used for personal use not related to business and registered to you or a household family member. If your vehicle doesn't fit into this category, select one of the options below:
Business Auto if the auto is a business use vehicle.
Antique Auto if the vehicle is used mainly for exhibitions, club activities or parades.
Commercial Vehicle if the vehicle is a large size vehicle (2 1/2 ton or more) and used regularly in a business.
Public Auto if the vehicle is a taxi, limousine, bus or shuttle bus.
Garaging Information
What is your name?
Last
First
Middle
What is the garaging address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
Mailing Address
What is your mailing address? (if different from above)
Street
City
State
Zip
Driver Information
Driver 1
First Name
Last Name
Gender
Male
Female
Date of Birth
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2
First Name
Last Name
Gender
Male
Female
Date of Birth
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3
First Name
Last Name
Gender
Male
Female
Date of Birth
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4
First Name
Last Name
Gender
Male
Female
Date of Birth
Marital Status
Years Licensed
State Licensed
Occupation
Vehicle Information
Vehicle 1
Year
Make
Model
Miles per year
Parked at night
Airbag (drivers)
Yes
No
Airbag (dual)
Yes
No
Auto-
matic seat belts
Yes
No
Anti-lock brakes
Yes
No
Anti-theft device
Yes
No
Owner-
ship
Vehicle 2
Year
Make
Model
Miles per year
Parked at night
Airbag (drivers)
Yes
No
Airbag (dual)
Yes
No
Auto-
matic seat belts
Yes
No
Anti-lock brakes
Yes
No
Anti-theft device
Yes
No
Owner-
ship
Vehicle 3
Year
Make
Model
Miles per year
Parked at night
Airbag (drivers)
Yes
No
Airbag (dual)
Yes
No
Auto-
matic seat belts
Yes
No
Anti-lock brakes
Yes
No
Anti-theft device
Yes
No
Owner-
ship
Vehicle 4
Year
Make
Model
Miles per year
Parked at night
Airbag (drivers)
Yes
No
Airbag (dual)
Yes
No
Auto-
matic seat belts
Yes
No
Anti-lock brakes
Yes
No
Anti-theft device
Yes
No
Owner-
ship
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Coverage Information
  Bodily Injury Property Damage
Personal liability
Uninsured motorist
Medical payment  
Deductible Information
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comp (theft)
Collision
Miscellaneous Information
Current Insurance Company
Expiration date
Current premium
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Keystone Financial Advisors

50 Main Street, Suite 1000 | White Plains, NY 10606
Phone (914) 682-2190
Fax (914) 931-8400
 
 
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