Kleinschmidt Insurance—Auto Insurance Quote Request

QUOTE FORMS

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CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as driving records, credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Current Policy Information
Are you currently insured? Yes No
If No, why not?
If Yes, by what company?
Policy expiration date (mm/dd/yy):
Current annual premium:
Driver Information (include all licensed drivers in your household)
Driver #1
Driver's name:		Relation:
Birthdate (mm/dd/yy): Gender: M FMarital status: Married Single
Drivers licence information: DL#: City: State: Years licensed:
Driving history (past 3 years): #Tickets: #Accidents: #DUI/DWAI (past 5 years): SR-22 Filing: Yes No Drivers Ed: Yes No Accident prevention: Yes No
Driver #2
Driver's name:		Relation:
Birthdate (mm/dd/yy): Gender: M FMarital status: Married Single
Drivers licence information: DL#: City: State: Years licensed:
Driving history (past 3 years): #Tickets: #Accidents: #DUI/DWAI (past 5 years): SR-22 Filing: Yes No Drivers Ed: Yes No Accident prevention: Yes No
Driver #3
Driver's name:		Relation:
Birthdate (mm/dd/yy): Gender: M FMarital status: Married Single
Drivers Licence Information: DL#: City: State: Years licensed:
Driving History (past 3 years): #Tickets: #Accidents: #DUI/DWAI (past 5 years): SR-22 Filing: Yes No Drivers Ed: Yes No Accident prevention: Yes No
NOTE: If you have more than three drivers in your household, submit this form additional times. Just include your name in the Contact section and the information about the additional drivers.
Vehicle Information
Car #1
Yr: Make (e.g., Ford): Model (e.g., Focus): Leased? Y N
Body type (2 Dr, 4 Dr, Van, etc.): Vehicle ID# (VIN):
Annual mileage: Drive to school/work? Yes No #miles one-way:
Car alarm? Yes No # Airbags: 1 2 None Anti-lock brakes: Y N Automatic seat belts? Yes No
Comprehensive deductible $50 $100 $150 $250 $500 $1000	Collision deductible $50 $100 $150 $250 $500 $1000	Rental reimbursement: Yes No Towing and labor: Yes No
Car #2
Yr: Make (e.g., Ford): Model (e.g., Focus): Leased? Y N
Body type (2 Dr, 4 Dr, Van, etc.): Vehicle ID# (VIN):
Annual mileage: Drive to school/work? Yes No #miles one-way:
Car alarm? Yes No # Airbags: 1 2 None Anti-lock brakes: Y N Automatic Seat Belts? Yes No
Comprehensive deductible $50 $100 $150 $250 $500 $1000	Collision deductible: $50 $100 $150 $250 $500 $1000	Rental reimbursement: Yes No Towing and labor: Yes No
Liability Coverage
Tort option (if applicable): NA Limited Full Uninsured motorists: Minimum 25/50 50/100 100/300 150/500 None	Liability coverage: Minimum 25/50 50/100 100/300 250/500 300 csl 500 csl Personal injury protection: Basic Full Additional None	Property damage: Minimum 10,000 25,000 50,000 100,000
NOTE: If you have more than two automobiles to insure, submit this form additional times. Just include your name in the contact section and the information about the additional autos.
Additional Considerations/Requests
Please provide any additional comments you feel appropriate for this quote: