Please use this form to request a 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.
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1. Personal information * Your Last Name: First Name: M.I. * Home Address: * City: State: Zip: Home Phone: Number of Household Members: * E-mail Address: 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 Vehicle 1 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 Vehicle 2 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 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 Vehicle 1 Broad Standard Limited Deductible Vehicle 2 Broad Standard Limited Deductible Vehicle 3 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 Place of Employment: Occupation: 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: Birth Date: Sex: Male Female Marital Status Pick One Married Single Divorced Widowed Place of Employment: Occupation: 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 3 Driver 3 Name: Birth Date: Sex: Male Female Marital Status Pick One Married Single Divorced Widowed Place of Employment: Occupation: 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):