Auto Quote

General Information

Name:
Address:
City:	State: ZIP:
County:	Email:
Phone Day:
Best time to call:	Morning Afternoon
Occupation:
How long at current job:	years months

Current Auto Policy Information:

Company Name:

Policy Exp. Date:

/ / Premium: $

Term:

6 Months 1 Year Other

Personal Injury
Lawsuit Threshold:

Yes No (Verbal/Zero)

Limits / Deductibles:

Liability Limits	Collision Deductible	Other than Collision Deductible	PIP Options

Auto Claims:

Date	Type	Amount Paid	At Fault?
		$	Yes No
		$	Yes No
		$	Yes No

Vehicle Information:

(include all cars you or your family members own or lease)

Car #1	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #1
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip:

Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)

Name of Title Holder
Annual Mileage
Drive to school, work, station? Yes No
# of miles (one way): Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No

If vehicle is kept at an address other than that listed above, please indicate:
Location City: State: Zip:

(include all cars you or your family members own or lease)

Car #3	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #3
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip:

(include all cars you or your family members own or lease)

Car #4	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #4
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip:

Driver Information:

(including all licensed drivers in your household)

Driver's Name ---------- Sex	Occupation ---------- Marital Status	Relation to you	Date of birth (Mo/Day/Yr)	Driv. Lic. # ---------- State Licensed	Completed		# of Yrs. Licensed	% of Vehicle Use
Driver's Name ---------- Sex	Occupation ---------- Marital Status	Relation to you	Date of birth (Mo/Day/Yr)	Driv. Lic. # ---------- State Licensed	Drivers Education Course	Accident Prevention Course	# of Yrs. Licensed	#1	#2	#3

Male Female	Married Single	Self			Y N	Y N
Male Female	Married Single	Self			Y N	Y N
Male Female	Married Single	Self			Y N	Y N
Male Female	Married Single	Self			Y N	Y N
Must add to:								100%	100%	100%

Driver History

If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
Yes No
If yes, please answer the following:

Driver	Date	Type of Conviction	Fines	Speed Over Limit
	//		$	MPH
	//		$	MPH
	//		$	MPH
	//		$	MPH

2. Had his/her license suspended or revoked?
Answer only if "yes":

Driver	Suspended	Revoked
	Yes	Yes
	Yes	Yes
	Yes	Yes

3. Been convicted of driving under the influence of alcohol or drugs?
Answer only if "yes":

Driver	Alcohol	Drugs
	Yes	Yes
	Yes	Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
Yes No
If yes, please answer the following:

Driver	Date	Cost	Fines	Injuries	At Fault	Description
	//	$	$	Y N	Y N
	//	$	$	Y N	Y N
	//	$	$	Y N	Y N

Additional Comments:

Please give any additional comments about the coverage you desire:

Send mail to Webmaster@marianoagency.com with questions or comments about this web site. Copyright © 2000 J.A. Mariano Agency, M Pizzo LLC

Send mail to Webmaster@marianoagency.com with questions or comments about this web site.
Copyright © 2000 J.A. Mariano Agency, M Pizzo LLC