FREE 
AUTO INSURANCE QUOTE QUESTIONNAIRE
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.






(215) 721-4700
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.