Auto Quote Sheet
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1GREGORY INSURANCE GROUP
Auto Quote Sheet
Name:________________________________ DL#__________________ SSN ____________________
DOB:__________________ Education:_______________ Occupation:__________________________
Spouse: ______________________________ DL#___________________ SSN____________________
DOB:__________________ Education:_______________ Occupation:__________________________
Address:_____________________________________________________________________________
Years at address location:____________________
Year:__________ Make:_____________________ Model:_____________________
VIN (17 digits):_______________________________________________________
Purchased new? _______ If yes, do you want GAP coverage? ________
Odometer reading:___________ Commute miles: __________ Avg Annual Miles: _____________
Current Company/Coverages:_____________________________________________________________
Rental
Towing
Deductibles: Comp:_____________ Coll:_______________
Any special accessories? (Wheels, Stereo, TV’s, etc…)
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Auto:
Year:__________ Make:_____________________ Model:_____________________
VIN (17 digits):_______________________________________________________
Purchased new? _______ If yes, do you want GAP coverage? ________
Odometer reading:___________ Commute miles: __________ Avg Annual Miles: _____________
Current Company/Coverages:_____________________________________________________________
Rental
Towing
Deductibles: Comp:_____________ Coll:_______________
Any special accessories? (Wheels, Stereo, TV’s, etc…)
Any accidents or tickets within the last 5 years? ____________________________________________
_____________________________________________________________________________________
Other Drivers:
Name:______________________ DL#_______________ DOB:_______________
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Parent category: Financial