Automobile Form from Dunn & Associates Insurance, Inc.

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Personal Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Email:

Current Policy Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year
*Current homeowners* carrier:**	Expiration Date:

Vehicle Information
(include all cars owned or leased by you or your family)
Car #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Lease or Own?		Annual Mileage	Drive to school/work? Miles one way,		Airbags	Car Alarm
Lease Own			Y N (miles)		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Lease or Own?		Annual Mileage	Drive to school/work? Miles one way		Airbags	Car Alarm
Lease Own			Y N (miles)		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Lease or Own?		Annual Mileage	Drive to school/work? Miles one way		Airbags	Car Alarm
Lease Own			Y N (miles)		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #4	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Lease or Own?		Annual Mileage	Drive to school/work? Miles one way		Airbags	Car Alarm
Lease Own			Y N (miles)		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Liability Limit (ALL Cars)
Choose either Bodily Injury and Property Damage Bodily Injury Property Damage	or Single Limit Single Limit

Deductibles
Car#	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes
4			Yes	Yes

Driver Information
(include all licensed drivers in household)
Driver #1	Driver's Name		Drivers License Information
			DL#: State: Yrs Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver Information
(include all licensed drivers in household)
Driver #2	Driver's Name		Drivers License Information
			DL#: State: Yrs Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver Information
(include all licensed drivers in household)
Driver #3	Driver's Name		Drivers License Information
			DL#: State: Yrs Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver Information
(include all licensed drivers in household)
Driver #4	Driver's Name		Drivers License Information
			DL#: State: Yrs Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations* in the past 3 years*
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph
			$	mph
			$	mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions* below*
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver	Date	Description	Cost	Fines	Injuries	At Fault
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes

Additional Comments

Please add any additional comments you feel necessary for this quotation. If you have additional information for which there was not enough space above, such as additional drivers, vehicles, driver histories, etc..., please enter here.

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Home : About : Staff : Personal Coverages : Business Coverages : Financial Coverages : Employee Benefits :
Individual Life & Health : Contact

Dunn & Associates Insurance, Inc.	Phone: (386) 255-2477
324 W. International Speedway Blvd.	Fax: (386) 255-3573
Daytona Beach, FL 32114-4289

Email: info@dunn-insurance.com