Home & Auto Quote Sheet Page 2
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3Taylor-Palmer Agency, Inc.
Home & Auto Quote Sheet
Auto
Previously Cancelled? Yes No
Current Insurer: ____________________________________________
Current Limits: _________________________________ Expiration: __________ Years with Insurer: ______
Accidents/Violations in past 5 years? Yes No
Date
Driver
Accident/Violation Type
Amount Paid
___________ __________________ _________________________________________ __________________
___________ __________________ _________________________________________ __________________
___________ __________________ _________________________________________ __________________
Garaging Location: ___________________________________ Former Address: ________________________
Years at Current Address: ____
Residents in Household:
Gender
DOB
M/S/Div
License State & Number
1) _____________________ ________ ____________ ________ __________________________________
2) _____________________ ________ ____________ ________ __________________________________
3) _____________________ ________ ____________ ________ __________________________________
4) _____________________ ________ ____________ ________ __________________________________
#1) Year: ______ Make: ___________________________ Model: ____________________________________
VIN #: _______________________ Principal Operator: ____________________ Use: Pleasure Commute
Miles to Work: _____ Used for Delivery? Yes No Lienholder: ___________________________________
Liability
Comprehensive
Collision
Towing and Labor
Rental Reimbursement
#2) Year: ______ Make: ___________________________ Model: ____________________________________
VIN #: _______________________ Principal Operator: ____________________ Use: Pleasure Commute
Miles to Work: _____ Used for Delivery? Yes No Lienholder: ___________________________________
Liability
Comprehensive
Collision
Towing and Labor
Rental Reimbursement
#3) Year: ______ Make: ___________________________ Model: ____________________________________
VIN #: _______________________ Principal Operator: ____________________ Use: Pleasure Commute
Miles to Work: _____ Used for Delivery? Yes No Lienholder: ___________________________________
Liability
Comprehensive
Collision
Towing and Labor
Rental Reimbursement
#4) Year: ______ Make: ___________________________ Model: ____________________________________
VIN #: _______________________ Principal Operator: ____________________ Use: Pleasure Commute
Miles to Work: _____ Used for Delivery? Yes No Lienholder: ___________________________________
Liability
Comprehensive
Collision
Towing and Labor
Rental Reimbursement
Would you like an Umbrella Quote? Yes No
Additional Info: ____________________________________________________________________________
__________________________________________________________________________________________
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Parent category: Financial