Lee County Inside

This form is a request for PERSONAL AUTO insurance coverage. Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Information

Name:

Address:

City:

State:

Zip:

Day Phone:

Eve. Phone:

Beeper:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Day Phone Eve. Phone Beeper
Cell Email

Current Policy Information

Agent:

Insurance Company:

If none enter "None"

Policy Number:

Policy Expiration Date:

Total # of cars in house:

Total # of people in household
(Not just drivers):

Vehicle Information
(include all cars you or your family members own or lease)

Veh #1	Year	Make	Model	Body Style	Vehicle ID# (VIN) *required

Primary Driver		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
Is vehicle kept at an address other than that listed above please indicate address below.
Location Any Business Use? Yes No

Veh #2	Year	Make	Model	Body Style	Vehicle ID# (VIN) *required

Primary Driver		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
Is vehicle kept at an address other than that listed above please indicate address below.
Location Any Business Use? Yes No

Veh #3	Year	Make	Model	Body Style	Vehicle ID# (VIN) *required

Primary Driver		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
Is vehicle kept at an address other than that listed above please indicate address below.
Location Any Business Use? Yes No

Veh #4	Year	Make	Model	Body Style	Vehicle ID# (VIN) *required

Primary Driver		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
Is vehicle kept at an address other than that listed above please indicate address below.
Location Any Business Use? Yes No

Liability Limit (will be applied to all cars)

Choose Bodily Injury, Property Damage and Uninsured Motorist.

Bodily Injury

Property Damage

Uninsured Motorist

Deductibles
Veh#	Comprehensive	Collision	Rental	Towing
1
2
3
4

Driver Information (include all licensed drivers in your household)
Driver #1	Name		Drivers License Information *required
			DL#: State: Years Licensed:
Social Security Number		DOB *required	Sex	Marital Status
			M F	Married Single
Courses Completed Last 3 yrs:		Drivers Ed: Y N	Good Student: YN	Accident Prevention: Y N

Driver Information (include all licensed drivers in your household)
Driver #2	Name		Drivers License Information *required
			DL#: State: Years Licensed:
Relation		DOB *required	Sex	Marital Status
			M F	Married Single
Courses Completed Last 3 yrs:		Drivers Ed: Y N	Good Student: YN	Accident Prevention: Y N

Driver Information (include all licensed drivers in your household)
Driver #3	Name		Drivers License Information *required
			DL#: State: Years Licensed:
Relation		DOB *required	Sex	Marital Status
			M F	Married Single
Courses Completed Last 3 yrs:		Drivers Ed: Y N	Good Student: YN	Accident Prevention: Y N

Driver Information (include all licensed drivers in your household)
Driver #4	Name		Drivers License Information *required
			DL#: State: Years Licensed:
Relation		DOB *required	Sex	Marital Status
			M F	Married Single
Courses Completed Last 3 yrs:		Drivers Ed: Y N	Good Student: YN	Accident Prevention: Y N

Driver Violations List ALL moving traffic violation convictions for ANY driver in the past 3 years (MVR will verify)
Driver	Date	Type of Conviction	License Suspended or Revoked
			Suspended Revoked
			Suspended Revoked
			Suspended Revoked
			Suspended Revoked

Please list ALL accidents, regardless of fault, in the past 5 years
Driver	Date	Description	Injuries	At Fault
			Yes	Yes
			Yes	Yes
			Yes	Yes
			Yes	Yes

Additional Information Section
In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages extenuating circumstances, etc.