| Print - Complete - Fax for Miscellaneous Quote Associates Insurance Network, LLC Email AssocIns2006@yahoo.com Today's Date ____/____/_______ Phone 985-224-1314 Fax 985-224-4145 Renewal Date ____/____/_______ Referred by:_________________________ Phone #____-_____-______ Fax#____-_____-______ Named Insured:______________________ Type of Insurance Requested:_____________________ Insured 1: _______________________________ BDay: ___/___/_____ Male/ Female: _______ Drivers License#___________________ State ______________ SS# _____________ Insured 2: _______________________________ BDay: ___/___/_____ Male/ Female: _______ Drivers License#___________________ State ______________ SS# _____________ Physical Address: _________________________ City: _______________ Zip Code_________ Contact Phone: _(_____)________________ Ext. _______ Business or Personal?_______________ Tax ID Number:____________________________ Current Co.: ______________ 6 Month Premium: $_______ How Many Yrs? ______ Describe Vehicle: __________________________________________________________________ Veh#1 Year: _____ Make:________ Model:__________ VIN:______________________ Other____ Liab:___/___/___ UM:___/___/___ Med Pay:$_____ Towing:$______ Rental:$_______ Deductibles-#1 Comp$_____ Coll$_____Any Violations/Accidents/Claims in 5 years?____________ Describe Property: ________________________________________________________________ Value$________ Loan Amt?________ Living Sq Ft?______ Lenght/ Width___/____ Yr. Built _______ Construction Type?_________ Central Air/Heat?___# Stories:__ Bankruptcy in 5 Yrs?_____ Roof Type?________ SmokeDet/DeadBolts/FireExt.____ Local Alarm:__ Flood Ins?________ Any Losses in 5 yrs?___ Date___/___/____ Type____________ Amt:$_______ Describe Any Special coverage needs?_________________________________________________ OTHER TYPES OF INSURANCE:________________________________________________________ ________________________________________________________________________________ "To provide an accurate quotation we need to request a few reports that verify driving records, prior losses, and insurance scores. This is the reason we request the Drivers License and SS#. |
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