Auto Insurance Quote Application
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If you need space for additional drivers or vehicles, click here for the supplemental page.
Please print this form, fill it out, and mail it to: Posey Insurance Agency, 935 20th Street, Haleyville, AL 35565 or fax it to: 205-486-5422.
Date__________________
Address_________________________________________________________________
City__________________________State______Zip_______________________
Phone Home( )_____________Work( )______________Cell( )_______________
Place of Employment___________________________Occupation__________________
Driver’s License Number____________________ Issued Date _____________________
Social Security Number______-____-________
Date of Birth_______________________________ Age__________
Violations (Past 5 Years) Type______________________ Date_____________
Accidents (Past 5 Years) Type______________________ Date_____________
Comp Claims (Past 5 Years) Type______________________ Date_____________
Name _________________________________________________________________
Address________________________________________________________________
City__________________________State______Zip_______________________
Phone Home (___)____________ Work(__)_____________ Cell(__)_______________
Place of Employment___________________________Occupation__________________
Driver’s License Number____________________ Issued Date_____________________
Social Security Number______-____-________
Date of Birth_______________________________ Age________
Violations (Past 5 Years) Type______________________ Date_____________
Accidents (Past 5 Years) Type______________________ Date_____________
Comp Claims (Past 5 Years) Type______________________ Date_____________
Other than your spouse, is there anyone in the household that is 15 years or older?
Yes _____ No ______
If so, they will have to be listed and rated or excluded.
Vehicle
Information:
Vehicle 1:
Year ___________ Make ____________________ Model _________________
VIN #
___________________________________________________________
How many miles will this vehicle be
driven annually? ___________________
Is this vehicle used for business
purposes? Yes ________No _____
If so, what type of business?
_______________________________________
Odometer Reading: ________________ Market Value: _________________
Vehicle 2:
Year __________ Make ___________________ Model ___________________
VIN # ____________________________________________________________
How many miles will this vehicle be driven annually? _____________________
Is this vehicle use for business purposes? Yes _____ No _____
If so, what type of business? _____________________________
Odometer Reading: _________________ Market Value: ________________
Insurance:
Are you currently insured? Yes _______ No ________
Insurance Company Name: _____________________________________
Effective Date: _____________________________________________
Expiration Date: ____________________________________________
Policy Limits: BI _____________________ PD _________________
Has Insured had coverage for at least 6 months? Yes ____ No _______
Housing:
Do you own your own home? Yes ______ No ______
Home _____ Mobile Home ________ 10 years or newer? Yes ___ No ___
Do you have a homeowner’s insurance policy? Yes ____ No ____
Have you moved in the last 90 days? Yes _____ No _________
If yes, what was your previous address? ______________________________
City _____________ State _________________ Zip Code __________
Do you have a checking account at a bank? Yes ____ No _____
Do you have any major credit cards? Yes ____ No _____
Have you filed for bankruptcy in the past 3 years? Yes ____ No _____
Loss
Payee/Lienholder Information:
Name ___________________________________________
Address _________________________________________________
City __________________ State ______________ Zip _________
Phone (___) __________________ Fax (___) _________________
Coverage:
Do you want liability only? Yes _______ No ________
Named Insured Signature: ________________________________
Date__________________ Time: ___________