FREE
AUTO INSURANCE QUOTE QUESTIONAIRE
CUSTOMER INFORMATION

First Name                                               Middle Initial                            Last Name

Street Address  Apartment or Unit Number

City or Town   State               Zip Code   -  

Contact TelephoneBest Time To Reach You

Preferred Method of Contact (phone, e-mail, regular mail)

DRIVER #1
INFORMATION

First Name                                               Middle Initial                            Last Name

Drivers License Number   Date of Birth

Social Security Number            Marital Status

State or Country that issued Drivers License (list one)

Has your license been suspended or revoked in the last 3 years

If yes, please specify the reason

Any accidents or tickets in the last 3 years

If yes, please specify date and describe accident or ticket:

  DRIVER #2 (if any)
INFORMATION

First Name                                               Middle Initial                            Last Name

Drivers License Number   Date of Birth

Social Security Number            Marital Status

State or Country that issued Drivers License (list one)

Has your license been suspended or revoked in the last 3 years

If yes, please specify the reason

Any accidents or tickets in the last 3 years

If yes, please specify date and describe accident or ticket:


DISCOUNT QUESTIONS

Are you currently insured If so, for how many years or months

Please list your current or prior insurance company

Current or prior insurance policy number

Current or prior insurance policy expiration date

Do own a homeDo you currently have a mortgage or are employed with GMAC      

Are you a member of AAADid you ever take a driver improvement course


VEHICLE INFORMATION
VEHICLE # 1

YearMake     Model Alarm System

VIN (Vehicle Identification Number)        Number of Airbags

Automatic Seatbelts

Any existing or prior physical damage on the vehicle that we should be aware of


VEHICLE # 2 (if any)

YearMake         Model   Alarm System

VIN (Vehicle Identification Number)    Number of Airbags

Automatic Seatbelts

Any existing or prior physical damage on the vehicle that we should be aware of


COVERAGE QUESTIONS

Is this a quote request for state minimum liability only coverage     

Do you need collision or comprehensive coverage

Additional Comments:        


SPECIAL NOTE

For an apples-to-apples comparison of your current auto insurance please fax a copy of your current Declarations Page which will show us exactly what coverages you have now to 215-721-4727.  Quotes are ready the same day they are requested.  If you have any problems or questions please e-mail us at jeffreyfkratz@aol.com or call us directly at 215-721-4700.





  
Call today 215.721.4700
Please complete the questionaire as best as you can, click Submit at the bottom of the screen and one of our licensed insurance agents will provide you with a detailed, FREE Auto Insurance Quote the same day.  Any questions, please e-mail us at jeffreyfkratz@aol.com or call us directly at 215-721-4700.