Wartick Insurance Agency
Auto Quote
Page 1
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Name
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First Name
Last Name
Address
Address
Address Line 2
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Alabama
Alaska
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District of Columbia
Florida
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Armed Forces(AA)
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Armed Forces(AP)
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Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
City
State
Zip Code
Home Phone
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Phone Number
Work Phone
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Phone Number
Are you currently insured and If not, why not?
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Present Auto Ins. Co
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Renewal Date
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Click in box to select date
Own Home?
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Yes
No
Car #1
Year
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Make
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Model
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Type
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2dr
4dr
Miles to work (one way)
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Annual Mileage
required
Type of Anti - Theft device on vehicle
required
VIN#
required
Car #2
Year
required
Make
required
Model
required
Type
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Select one
2dr
4dr
Miles to work (one way)
required
Annual Mileage
required
Type of Anti - Theft Device on vehicle
required
VIN#
required
Car #3
Year
required
Make
required
Model
required
select one
Select one
2dr
4dr
Miles to work (one way)
required
Annual Mileage
required
Type of Anti - Theft device on vehicle
required
VIN#
required
Page 2
page 2 of 3
Driver #1 Information
Driver Name
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Occupation
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Business
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Length of job
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Highest level of Education
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Date of Birth
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Click in box to select date
Drivers License Number
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Gender
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Select one
Male
Female
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Select from list
Single
Married
Moving violations in the last 5 years
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Select one
0
1
2
3
Please provide the date and a brief description of each violation
required
Accidents in the last 5 years
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Select one
0
1
2
3
Please provide the date and a brief description of each accident
required
Driver #2
Driver Name
required
Occupation
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Business
required
Length of current job
required
Highest level of Education
required
Date
required
Click in box to select date
Drivers License Number
required
select one
Select one
Male
Female
Marital Status
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Select from list
Single
Married
Moving Violations in the last 5 years
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Select one
0
1
2
3
Please provide the date and a brief description of each violation
required
Accidents in the last 5 years
select one
Select one
0
1
2
3
Please provide the date and a brief description of each accident
required
Driver #3
required
Driver Name
required
Occupation
required
Business
required
Length of current job
required
Highest level of education
required
Date
required
Click in box to select date
Drivers license number
required
Gender
select one
Select one
Male
Female
Marital Status
select one
Select from list
Single
Married
Moving violations in the last 5 years
select one
Select one
0
1
2
3
Please provide the date and a brief description of each violation
required
Accidents in the last 5 years
select one
Select one
0
1
2
3
Please provide the date and a brief description of each accident
required
Page 3
page 3 of 3
Liability Limit for all Cars
Bodily Injury
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30,000 / 60,000
50,000 / 100,000
100,000 / 300,000
250,000 / 500,000
Property Damage
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25,000
50,000
100,000
500,000
Single Limit (choose one)
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60,000
100,000
300,000
500,000
Levels of current Uninsured Motorist coverage
required
Car #1
Deductible Comprehensive
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100
250
500
Deductible Collision
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Select one
250
500
1000
Tow
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Select from list
Yes
No
Loss of use
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Select from list
Yes
No
Car #2
Deductible Comprehensive
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Select one
100
250
500
Deductible Collision
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Select one
250
500
1000
Tow
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Select from list
Yes
No
Car #3
Deductible Comprehensive
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Select one
100
250
500
Deductible Collision
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Select one
250
500
1000
Tow
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Select from list
Yes
No
Loss of Use
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Select from list
Yes
No
Comments
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