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Personal Auto
- Request for Proposal
Personal Information
Name:
Address:
City
State:
Zip:
Home Phone:
Work Phone:
Email Address:
Driver(s)
Name
Age
License #
Years
Licensed
Marital Status
Not Selected
Married
Single
Widowed
Divorced
Not Selected
Married
Single
Widowed
Divorced
Not Selected
Married
Single
Widowed
Divorced
Not Selected
Married
Single
Widowed
Divorced
List any tickets and/or accidents within the past five years for the drivers listed above (Give details):
Auto(s)
Year
Make & Model
Annual Mileage
Comp/Collision Deductible
Cost New
Limits Desired
Liability / Property Damage
Medical Payments
Uninsured Motorist
Not Selected
$15,000 | $30,000 | $5,000
$15,000 | $30,000 | $10,000
$25,000 | $50,000 | $15,000
$25,000 | $50,000 | $25,000
$50,000 | $100,000 | $25,000
$50,000 | $100,000 | $50,000
$100,000 | $300,000 | $25,000
$100,000 | $300,000 | $50,000
$100,000 | $300,000 | $100,000
$250,000 | $500,000 | $100,000
$250,000 | $500,000 | $250,000
$300,000 | $300,000 | $100,000
$300,000 | $300,000 | $300,000
Not Selected
$500
$1,000
$2,000
$5,000
Not Selected
$15,000 | $30,000
$25,000 | $50,000
$30,000 | $60,000
$50,000 | $100,000
$100,000 | $300,000
$250,000 | $500,000
Optional coverage's
Rental Reimbursement:
Yes
No
Towing & Labor:
Yes
No
Credits
Good Student
LA County Bar
Engineers & Scientists
Educator
LoJack/Teletrac
Current Insurance Company
Name of Company Insured by:
Expiration Date of current policy:
Number of years with prior insurance:
Claims over the past five years (Give details):
License #: 0578496
Copyright Vicencia & Buckley Insurances Services Inc.
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