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Automobile Quote (Florida Only)
You will be contacted within 1 business day by our agent
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.

PERSONAL INFORMATION
Your Name: First:        Last:     
E-Mail address:     
Phone numbers: Day Time:
Evening:
Fax:
How would you prefer to be contacted
regarding your quote?
If you would prefer to be contacted by phone,
please let us know the best time to call.
Address:    
City:    
State:   (You must live in Florida)
Zip code:     
Do you currently own your home, or rent?
Social security number: (optional but may improve premium)
DRIVER INFORMATION
Driver Name: Relationship to applicant License Number Sex: Marital status: Date Of Birth:
  #1  

 

   

   
 #2

 

  
 #3  

 
 #4  

 
DRIVER HISTORY
Currently insured with (company name not agency):

Num of Months Coverage:

 Date Expires:
Prior Policy Number: Prior Bodily Injury Limits:
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 last3 years? Had a financial responsibility filing in the last 3 years? Made any claims in the last 5 years?




If you answered yes to any of the above questions, please explain:
VEHICLE #1 INFORMATION
Year: Make: Model: Vehicle ID# (VIN):
             
Is the vehicle in any way modified or customized? Is there any existing damage to the vehicle?
VEHICLE #2 INFORMATION
Year: Make: Model: Vehicle ID# (VIN):
   
Is the vehicle in any way modified or customized? Is there any existing damage to the vehicle?
VEHICLE #3 INFORMATION
Year: Make: Model: Vehicle ID# (VIN):
Is the vehicle in any way modified or customized? Is there any existing damage to the vehicle?
VEHICLE #4 INFORMATION
Year: Make: Model: Vehicle ID# (VIN):
Is the vehicle in any way modified or customized? Is there any existing damage to the vehicle?
COVERAGE OPTIONS
Coverage Definition                      Bodily Injury Liability:
Property Damage Liability:
Uninsured Motorist:
Personal Injury Protection:
Medical Payments:
COVERAGE DEDUCTIBLES ADDITIONAL COVERAGE
  Comprehensive Deductible Collision Deductible Towing Rental
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

 

Close           
Bodily Injury Liability
Covers other people's injuries or death for which you are responsible. It also provides for a legal defense if another party in the accident files a lawsuit against you. Claims for bodily injury may be for such things as medical bills, loss of income or pain and suffering. In the event of a serious accident, you want enough insurance to cover a judgment against you in a lawsuit, without jeopardizing your personal assets. Bodily injury liability covers injury to people, not your vehicle. Bodily Injury does NOT cover you or other people on your policy.

Property Damage Liability
Covers you if your car damages someone else's property. Usually it is their car, but it could be a fence, a house or any other property damaged in an accident. It also provides you with legal defense if another party files a lawsuit against you. It is a good idea to purchase enough of this insurance to cover the amount of damage your car might do to another vehicle or object.

Personal Injury Protection Coverage
Covers within the specified limits, the medical, hospital and funeral expenses of the insured, others in his vehicles and pedestrians struck by him. The basic coverage for the insured's own injuries on a first-party basis, without regard to fault.

Medical Payments
Covers additional medical expenses to you and your passengers injured in an accident. There may also be coverage if as a pedestrian a vehicle injures you. Does NOT matter who is at fault.

Uninsured Motorist
Covers you, the insured members of your household and your passengers for bodily/personal injuries, damages or death caused by an at-fault uninsured or hit-and-run driver. If you are involved in an accident where the other driver is at fault but has no insurance, your policy will cover your medical expenses, up to the limit on your policy.

Comprehensive Coverage
Covers your vehicle, and sometimes other vehicles you may be driving for losses resulting from incidents other than collision. For example, comprehensive insurance covers damage to your car if it is stolen; or damaged by flood, fire, or animals. Pays to fix your vehicle less the deductible you choose. To keep your premiums low, select as high a deductible as you feel comfortable paying out of pocket.

Collision Coverage
Covers damage to your car when your car hits, or is hit by, another vehicle, or other object. Pays to fix your vehicle less the deductible you choose. To keep your premiums low, select as large a deductible as you feel comfortable paying out of pocket. For older cars, consider dropping this coverage, since coverage is normally limited to the cash value of your car.