Auto
Insurance Quotation Worksheet
Rating Information:
|
Drivers
|
Age
|
Sex
|
Marital Status
|
% Use of Auto
|
|
Principal driver
|
|
|
|
|
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Other driver
|
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|
|
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Other driver
|
|
|
|
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Other driver
|
|
|
|
|
Number of accidents or moving violations
in the past three years: __________
Automobiles To
Be Insured
|
|
Make
|
Model
|
Year
|
Annual Mileage
|
Work Mileage
|
|
Auto # 1
|
|
|
|
|
|
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Auto # 2
|
|
|
|
|
|
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Auto # 3
|
|
|
|
|
|
|
Auto # 4
|
|
|
|
|
|
Insurance Information:
Annual Premiums
|
Coverage
|
Deductible
|
Company "A"
|
Company "B"
|
Company "C"
|
Company "D"
|
|
Liability
|
|
|
|
|
|
|
Med Payments
|
|
|
|
|
|
|
Collision
|
|
|
|
|
|
|
Comprehensive
|
|
|
|
|
|
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Uninsured Motorist
|
|
|
|
|
|
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PIP
|
|
|
|
|
|
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Other
|
|
|
|
|
|
Total Annual Premiums:
