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   Auto Insurance Quote
Please complete the following general questionnaire. Our professional staff will contact you regarding your quote, or call us at (800) 779-PARS.
Your Personal Data
Your Name:
Street Address:
City:
State: CALIFORNIA
Zip Code:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Marital Status:
 Single Married 		Homeowner?
 Yes No
 
Currently Insured?
 (If yes, list carrier, and # of years
continuous. If none, type N/C)
Many Carriers Now Use Credit Scoring For Rates and Discounts. How would you honestly rate your credit strength & past payment history? Perfect Fair
Poor No Past Credit
DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensed:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensed:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $10/20 BI / 10 PD $25/50 BI / 25 PD
$50/100 BI / 50 PD $100/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $10/20 BI / 10 PD $25/50 BI / 25 PD
$50/100 BI / 50 PD $10/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
Comments or Remarks:
 (List additional drivers, autos, etc. here)
Send my quotation via: E-Mail Fax
Regular Mail
 Call me by Phone!
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
Yes, I Agree. Please Send Me the Quote NOW!

      

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