

		ASSESS YOUR DEDUCTIBLE : Raising it to $500 can result in a lower insurance premium. Just be sure you can afford to pay the deductible if you are in an accident.

Automobile Insurance Quote Application

Complete & send the following form to obtain your FREE Auto Insurance quote.

We will research many companies to find you the lowest premium for quality coverage.

This insurance application will allow you to request a quote for up to 4 vehicles and up to 4 drivers. When the form is submitted, the information will be sent to an agent in our office, who will generate a quote and email that information to you.

Be sure to have this information available in order to complete the application:
1. Name and date of birth for each driver.
2. Violations or accidents within the last 36 months.
3. Year and make/model or Vehicle Identification Model Number for each vehicle.

Please provide the following contact information:

Driver Information: (All drivers in your household must be listed on your quote.)

Driver One

Name: License Number
Gender:	Date of Birth:
Marital Status:	Years Licensed:

Driver Two

Name: License Number
Gender:	Date of Birth:
Marital Status:	Years Licensed:

Driver Three

Name: License Number
Gender:	Date of Birth:
Marital Status:	Years Licensed:

Driver Four

Name: License Number
Gender:	Date of Birth:
Marital Status:	Years Licensed:

Accident/Violation/Claim History (past 36 months)

Incident 1

Date: Driver:
Description:

Incident 2

Date: Driver:
Description:

Incident 3

Date: Driver:
Description:

Incident 4

Date: Driver:
Description:

Vehicle Information

Vehicle 1

	Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage:

Vehicle 2

Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage:

Vehicle 3

Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage:

Vehicle 4

Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage:

Coverage Information

Bodily Injury (Per Person/Per Accident):

Property Damage:

Medical Coverage:

Towing and Labor:

Extended Transportation:

Comprehensive Coverage:
Vehicle 1: Vehicle 2: Vehicle 3: Vehicle 4:

Collision Coverage:
Vehicle 1: Vehicle 2: Vehicle 3: Vehicle 4:

Other Coverages:

General Information

First Name:
Last Name:
Street Address:
City:
State:	Zip Code:
E-mail address:
Home Phone:	- -
Work Phone:	- -
How should we contact you?
Your occupation: Your Employer: Total number of years employed: years Current Insurance company: How long have you been continuously insured? How did you hear about Dalton Insurance Agency? Policy Expiration Date: Do you own your home? Yes No How long have you lived at your current residence? years Additional Comments: