Please use this form to request an auto insurance quotation from The White Agency. By completing this form as accurately and completely as possible, you help us deliver to you our best possible premium. (*required fields)
Please use this form to request an auto insurance quotation from The White Agency. By completing this form as accurately and completely as possible, you help us deliver to you our best possible premium.
(*required fields)
1. Personal information
* Your Last Name:
First Name:
M.I.
* Home Address:
* City:
State:
Zip:
Home Phone:
Number of Household Members:
2. Current insurance company information
Auto Insurance Company (type NONE if no current provider)
Expires
Liability Limits Pick One 50,000/100,000/25,000 100,000/300,000/100,000 250,000/500,000/100,000 300,000 Combined Limit 500,000 Combined Limit
Other liability
Health Insurance Company
3. Vehicle Information - (List only the vehicles you want insured)
Year
Make/Model
Vehicle ID#
Vehicle 1
Vehicle 2
Vehicle 3
Primary Use
Comprehensive
Collision
Must pick this Pleasure Work <3 Miles Work 3-15 Miles Work > 15 Miles Business
Pick one 50 100 250 500 1000 None
Pick one 100 250 500 1000 None
Pleasure Work < 3 Miles Work 3-15 Miles Work > 15 Miles Business Vehicle 2
If 2nd vehicle 50 100 250 500 1000 None
If 2nd vehicle 100 250 500 1000 None
vehicle 3 Pleasure Work < 3 Miles Work 3-15 Miles Work > 15 Miles Business
If 3rd vehicle 50 100 250 500 1000 None
If 3rd vehicle 100 250 500 1000 None
Collision Type
Broad
Standard
Limited Deductible
4. Driver Information
Driving Violations for each driver in last 5 years
Please complete for each driver
DRIVER 1
Driver 1 Name:
Birth Date:
Sex: Male Female
Marital Status Pick One Married Single Divorced Widowed
Violations
# of Violations
Date of Violations
None
Speeding (Up to 10 MPH over)
Speeding (11-15 MPH over)
Speeding (More than 15 MPH over)
Non at-fault accident
At-fault accident
Other Violations (explain and give dates):
DRIVER 2
Driver 2 Name:
DRIVER 3
Driver 3 Name:
Other Violations (explain):
