AUTO INSURANCE QUOTE

First & Last Name:
Address:
City, State & Zip:
E-Mail:
Telephone:
Do You Own Your Home?	Yes No

Vehicle Information
(List all cars you or your family own)

Vehicle 1:	Year	Make/Model
	Yearly Mileage	Usage
		Select... Pleasure Work over 3 miles Work less 3 miles Business
Vehicle 2:	Year	Make/Model
	Yearly Milage	Usage
		Select.. Pleasure Work over 3 miles Work less 3 miles Business
Vehicle 3:	Year	Make/Model
	Yearly Milage	Usage
		Select.. Pleasure Work over 3 miles Work under 3 miles Business

Coverage Information

Liability limits for injury & property damage:	Select.. 10/20/10 25/50/25 50/100/25 100/300/50 250/500/100

Deductibles

	Comp. & Collision	Towing	Rental Reimb.
Vechicle 1:	Select.. 100/100 100/250 100/500 100/1,000 250/100 250/250 250/500 250/1,000 500/100 500/250 500/500 500/1,000	Yes No	Yes No
Vechicle 2:	N/A 100/100 100/250 100/500 100/1,000 250/100 250/250 250/500 250/1,000 500/100 500/250 500/500 500/1,000	N/A Yes No	N/A Yes No
Vechicle 3:	N/A 100/100 100/250 100/500 100/1,000 250/100 250/250 250/500 250/1,000 500/100 500/250 500/500 500/1,000	N/A Yes No	N/A Yes No

Driver 1

Name:		Sex:	Male Female
DL #:		Martial Status:	Married Single
Date of birth:		Driver's Ed:	Yes No
S.S.N.		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 Filing?	Yes No

Driver 2

Name:		Sex:	Male Female
DL #:		Martial Status:	Married Single
Date of birth:		Driver's Ed:	Yes No
S.S.N.		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 Filing?	Yes No

Driver 3

Name:		Sex:	Male Female
DL #:		Martial Status:	Married Single
Date of birth:		Driver's Ed:	Yes No
S.S.N.		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 Filing?	Yes No

Accidents / Violations in the last 5 years?

Date	Driver	Violation	Cost ($)
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non fault accident DUI Other
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non fault accident DUI Other
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non fault accident DUI Other

List any DUI convictions, license suspensions or revocations:

Any additional comments or information that may be useful for your quote:

Centennial Insurance Group, Inc.™

 

I’m not too far removed from my law school contracts class, so I remember all too well the adage, “If it sounds too good to be true… It probably is.” 

That’s what came to mind when Centennial quoted me my rate.  I was sure this was “too good to be true,” because the quote was so much less than what I’d been paying. 

Well, after almost offending my agent by telling him that he was doing something wrong, I received the rates quoted to me. 

Thank you Centennial for the money that you guys are saving me!!!

Matthew S. Gore, Esq.