Do you currently have vehicle insurance? For how long?
Name of insurance company.
DRIVER INFORMATION:
Date of birth
Married
Sex
Licensed at what age
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Have any of the above drivers had any tickets or accidents
within the last five years? Please reference by driver number,
date of incident, nature of incident, and as much information as
you can provide, including amounts paid on claims.
If any of the above drivers are still enrolled in school, might they qualify for a "Good Student Credit" (B-average or better)?
Which driver(s)and
Do any of the above drivers require an SR-22 Filing.
Which driver(s)and
VEHICLE INFORMATION:
Year
Make
Model
VIN (Very Helpful!)
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VEHICLE USE:
Vehicle Used For:
If Commute, Miles One Way To Work
Estimated Annual Mileage
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LIABILITY LIMITS AND DEDUCTIBLES:
For purposes of simplification, our options include those most commonly requested by our clients. Other options are available.
Body Injury & Property Damage:
Uninsured Motorists: We will quote limits, which match your Bodily Injury/Property Damage Limits. Other options are available.
Medical Payments: If you chose State-Required Minimums for Bodily Injury/Property Damage, we will quote with a $1,000 Medical Payments limit. If you chose a higher limit, we will quote with a $5,000 limit. Other options are available.
Physical damage coverage: If you want comprehensive and/or collision coverage on any of the above-listed vehicles, please advise us of your preferred deductibles. The options shown are those most commonly requested by our customers. Lower and higher deductibles are available. The lower the deductible, the higher the premium, and vice versa.
Comprehensive
Collision
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If you want to specify other coverage options, please do here.
Our indication to you may include enhancements in addition to those listed above (such as towing and rental-car reimbursement coverage). You may accept or decline those options.
We will Email an insurance premium indication. Firm quotations are subject to confirmation of the information provided above as well as the receipt of additional underwriting information. Thank you for taking the time to contact TNT Insurance Agency about your personal auto insurance.
