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Automobile Quotes

PERSONAL INFORMATION
Name:	First:
	Last:
E-Mail address:
Phone numbers:	Daytime:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
Best time to call:
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:

DRIVER INFORMATION
	Name:	Relationship to applicant:	Sex:	Marital status:	Driver's age:	Which vehicle does he/she drive?	Percent use:
Driver #1			Male Female	Married Single
Driver #2			Male Female	Married Single
Driver #3			Male Female	Married Single
Driver #4			Male Female	Married Single

DRIVER HISTORY
Current Insurance Company (Not Agency):
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 last 6 years?	Had a financial responsibility filing in the last 6 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No
If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #2 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #3 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #4 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

COVERAGE OPTIONS
Underinsured motorist-property damage:
Underinsured motorist-bodily injury:
Bodily injury liability:
Property damage liability:
Medical-personal injury protection:
Accidental death:

COVERAGE DEDUCTIBLES
	Comprehensive deductible:	Collision deductible:	Towing coverage deductible:
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

Please note that completion of the above request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.
Larry Johnson Insurance & Financial Services is licensed in the state of Florida.

No solicitation of insurance is being made outside of this state.

Hurricane Season begins June 1. There is a 30 day waiting period on Flood Insurance.
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Watts Dawson & Associates, Inc.
13008 N. 56 Street        1139 Professional Park Dr.   2086 Edgewood Dr.
Tampa, FL 33617          Brandon, FL 33511               Lakeland, FL 33803
Phone: 813-985-0349    Phone: 813-651-9660            Phone: 863-688-1439
Fax: 813-989-3284         Fax: 813- 685-0424                  Fax: 863-682-4234
Email: office@wattsdawsoninsurance.com