Auto Quote
Telephone Number ______________________________________________
Name __________________________________ Birth ____ / ____ / ____
Social Security Number ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___
Drivers License Number ___ ___ ___ ___ --- ___ ___ --- ___ ___ ___ ___
Spouse _________________________________ Birth ____ / ____ / ____
Social Security Number ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___
Drivers License Number ___ ___ ___ ___ --- ___ ___ --- ___ ___ ___ ___
Address __________________________________________________________
City _________________________________ Zip _________________________
Child ___________________________________ Birth ____ / ____ / ____
Childs Drivers License Number ___ ___ ___ ___ --- ___ ___ --- ___ ___ ___ ___
Are your automobiles currently insured? ______ Yes ______ No
Current Insurance Carrier ___________________________________________
Date Current Insurance Policy Expires ________________________________
Protective Device Discounts: Seat Belts ____Yes ____No
Air Bags ____Yes ____No Security System ____Yes ____No
Autos to Insure:
Year_______Make ____________________ Model____________________________
Vehicle Identification Number:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Year_______Make ____________________ Model____________________________
Vehicle Identification Number:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Year_______Make ____________________ Model____________________________
Vehicle Identification Number:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Coverage Desired:
Bodily Injury Liability Coverage ___100/300 ____ 50/100 ___ 25/50 Other ___________________
(Property Damage Liability written at lowest limit of bodily injury liability)
(Uninsured & Underinsured Motorist Coverage is written with the same limits as Liability Coverage)
Medical Coverage ___ 10,000 _____ 5,000 ____ 1,000 Other____________________
Deductible for Collision ___500 ____250 Other____________________
Deductible for Comprehensive ___500 ____250 ____100 Other____________________
Do you want Car Rental Coverage? _____Yes _____No
Do you want Towing Coverage? _____Yes _____No
Tickets, Accidents, & Date Occurred in the last 3 years _________________________
_____________________________________________________________________
Please Fax to Jeff Rife - Rife Insurance Services FAX # (866) 711-0334