The Hart Smith Company: Automobile Insurance Quotation Form

AUTOMOBILE INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

The Hart Smith Company is licensed in the state of Georgia. No solicitation of insurance is being made outside of this state.

Personal Information
Your name
E-Mail address
Phone numbers	Daytime
	Evening
	Fax
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-Mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address City State, Zip
Do you currently own your home, or rent?	Own Rent
Driver's license number
Social security number

Driver Information
	Name	Relationship to Applicant	Sex	Marital Status	Driver's Age	Which Vehicle?	Percent Used
Driver #1
Driver #2
Driver #3
Driver #4

Driver History
Currently insured with (company name not agency)
Have you or any other driver in your household:
Had a ticket in the last 3 years?	Had a license suspended or revoked in the last 6 years?	Had a financial responsibility filing in the last 6 years?	Made any claims in the last 5 years?
If you answered yes to any of the above question, please explain:

Vehicle Information
Vehicle #1
Year	Make	Model	Vehicle ID# (VIN)
Primary Driver	Annual Mileage	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized? Yes No			Is there any existing damage to the vehicle? Yes No
If vehicle is kept at an address other than that listed above, please indicate below
Address: City: State: Zip:
Vehicle #2
Year	Make	Model	Vehicle ID# (VIN)
Primary Driver	Annual Mileage	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized? Yes No			Is there any existing damage to the vehicle? Yes No
If vehicle is kept at an address other than that listed above, please indicate below
Address: City: State: Zip:
Vehicle #3
Year	Make	Model	Vehicle ID# (VIN)
Primary Driver	Annual Mileage	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized? Yes No			Is there any existing damage to the vehicle? Yes No
If vehicle is kept at an address other than that listed above, please indicate below
Address: City: State: Zip:
Vehicle #4
Year	Make	Model	Vehicle ID# (VIN)
Primary Driver	Annual Mileage	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized? Yes No			Is there any existing damage to the vehicle? Yes No
If vehicle is kept at an address other than that listed above, please indicate below
Address: City: State: Zip:

Coverage Options
Bodily injury liability
Property damage liability
Underinsured motorist-bodily injury
Underinsured motorist-property damage
Medical-personal injury protection
Accidental death

Coverage Deductibles
Vehicle	Comprehensive	Collision	Towing
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Questions, Comments or Additional Automobile Information