FREE AUTO INSURANCE QUOTE QUESTIONNAIRE
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.
CUSTOMER INFORMATION
First Name:
Middle Initial:
Last Name:
Street Address:
Apartment or Unit #:
City or Town:
State:
Zip Code:
Contact Telephone:
Email Address:
DRIVER #1
First Name:
Middle Initial:
Last Name:
Drivers License Number:
Date of Birth:
SSN, Passport or Matriculation #:
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)
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 home?
Do you currently have a mortgage or are employed with GMAC?
Are you a member of AAA?
Did you ever take a driver improvement course?
VEHICLE INFORMATION
VEHICLE # 1
Year:
Make:
Model:
Alarm System:
VIN (Vehicle Identification Number):
# of Airbags:
Automatic Seatbelts?
Any existing or prior physical damage on the vehicle that we should be aware of?
VEHICLE # 2 (if any)
Year:
Make:
Model:
Alarm System:
VIN (Vehicle Identification 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 a FREE apples-to-apples comparison of your current Auto Insurance, please email a Copy of your current Declarations Pages which will show us exactly what Coverages you have now to: JeffreyFKratz@AOL.com for a Competitive Comparison Quote.
