AUTOMOBILE INSURANCE QUOTE

Oswald Insurance will provide a quotation based on the information provide us. The more precise, the better. Information submitted will be confidential.   

Fields marked with an asterisk * are required.

CONTACT INFORMATION
Your First Name:  *
How would you prefer to be contacted regarding your quote? Email Phone Fax*
Email Address: 
Fax Number:
Phone Number:
Best time to call:
Morning Afternoon Evening
Your Age: 
Do you currently own your home, or rent? Own Rent

DRIVER INFORMATION
  Name Relationship to applicant Sex Marital Status Driver's age Which vehicle does he/she drive primarily?
Driver #1 Male Female Married Single

Driver #2 Male Female Married Single

Driver #3 Male Female Married Single

Driver #4 Male Female Married Single

DRIVER HISTORY

Currently insured with (company name not agency)

Have you or any other driver in your household:
Any moving violations in the last 4 years? Made any claims in the last 4 years? Had a financial responsibility filing in the last 4 years? Had a license suspended or revoked in the last 6 years?
Yes
No		 Yes
No		 Yes
No		 Yes
No

If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year: Make: Model: Vehicle ID# (VIN)
Annual mileage Is the vehicle driven to school or work? If driven to school or work. how many miles one way?
Yes No Miles - one way to work or school
Do you want Full Coverage or Liability only on this vehicle? Full Coverage Liability Only

VEHICLE #2 INFORMATION
Year: Make: Model: Vehicle ID# (VIN)
Annual mileage Is the vehicle driven to school or work? If driven to school or work. how many miles one way?
Yes No Miles - one way to work or school
Do you want Full Coverage or Liability only on this vehicle? Full Coverage Liability Only

VEHICLE #3 INFORMATION
Year: Make: Model: Vehicle ID# (VIN)
Annual mileage Is the vehicle driven to school or work? If driven to school or work. how many miles one way?
Yes No Miles - one way to work or school
Do you want Full Coverage or Liability only on this vehicle? Full Coverage Liability Only

VEHICLE #4 INFORMATION
Year: Make: Model: Vehicle ID# (VIN)
Annual mileage Is the vehicle driven to school or work? If driven to school or work. how many miles one way?
Yes No Miles - one way to work or school
Do you want Full Coverage or Liability only on this vehicle? Full Coverage Liability Only
COVERAGE OPTIONS
Bodily injury and Property damage liability:

Underinsured motorist-bodily injury:

Medical-personal injury protection:

Accidental death:

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

*Are any vehicles kept at an address other than your home address? If so, please explain.
 

 

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