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) 536-2848.

If you have any problems or questions please e-mail JeffreyFKratz@AOL.com or call (215) 721-4700 today.






(215) 721-4700
Please complete the questionnaire as best as you can, click Submit at the bottom of the screen and you will be provided with a detailed, FREE Auto Insurance Quote. Any questions, please e-mail JeffreyFKratz@AOL.com or call (215) 721-4700 today.