Personal Auto Insurance Proposal Request
Georgia and Alabama Residents ONLY

For the fastest and most accurate automobile insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

Your Name:
Address:
City:	State:
Zip Code:	... County:
Home Phone:
Work Phone:
Fax:
E-Mail Address:
Date of Birth:
Drivers License Number:
Social Security Number:

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  Vehicle Description

Year	Make & Model - Please Be Specific	Body Style	Vehicle ID# - Enables Quote Accuracy
		Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible
		Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible
		Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible

Vehicle Use & Discounts

Vehicle	Vehicle Usage	Miles One Way	Driver Name	Airbags	Anti Lock Brakes	Auto Seat Belts
1.	Select Pleasure Drive to work Business Use			Select None One Two	Select None 2 wheels 4 wheels	Select No Yes
2.	Select Pleasure Drive to work Business Use			Select None One Two	Select None 2 wheels 4 wheels	Select No Yes
3.	Select Pleasure Drive to work Business Use			Select None One Two	Select None 2 wheels 4 wheels	Select No Yes

Driver Information

Driver	Driver Name	Sex	Date of Birth	Marital Status	Occupation
1.		Select Male Female		Select Single Married Divorced
2.		Select Male Female		Select Single Married Divorced
3.		Select Male Female		Select Single Married Divorced

Additional Driver Information & Discounts

Driver	Driver Training	Good Student	Smoker	Away at School	Defensive Driver
1.	Select No Yes	Select No Yes	Select No Yes	Select No Yes	Select No Yes
2.	Select No Yes	Select No Yes	Select No Yes	Select No Yes	Select No Yes
3.	Select No Yes	Select No Yes	Select No Yes	Select No Yes	Select No Yes

Please list all violations and accidents (including not-at fault accidents) for the last 5 years:


Liability / Uninsured Motorists / Medical Payments
Liability Limit - Bodily Injury Select $250,000 per person, $500,000 each accident $100,000 per person, $300,000 each accident $50,000 per person, $100,000 each accident $25,000 per person, $50,000 each accident $15,000 per person, $30,000 each accident
Liability Limit - Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident $10,000 each accident
Uninsured/Underinsured Motorists Limit Select $250,000 per person, $500,000 each accident $100,000 per person, $300,000 each accident $50,000 per person, $100,000 each accident $25,000 per person, $50,000 each accident $15,000 per person, $30,000 each accident None
Uninsured/Underinsured Motorists Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident $10,000 each accident
Medical Payments - Per Person Limit Select None $1,000 $2,000 $5,000 $10,000 $25,000 $50,000

Physical Damage Coverage & Deductibles

Vehicle	Comprehesive Deductible	Collision Deductible	Towing	Rental
1.	Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Coverage $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Yes	Select No Yes
2.	Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Coverage $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Yes	Select No Yes
3.	Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Coverage $100 deductible $250 deductible $500 deductible $1,000 deductible	Select No Yes	Select No Yes

Additional Information
Do you currently have insurance? Yes No
Who is you current auto insurance company?
When does your current policy expire?