First
Name |
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Last
Name |
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Apt # |
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Address |
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City |
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Zip
Code |
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Home
Phone |
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Work
Phone |
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Ext. |
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E-mail |
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Fax |
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Cell |
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Auto Information
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Year of
Auto |
Make of
Auto |
Model
Type |
#
of
Doors |
# of
Cylinders |
Driver
% Used |
Annual
Miles Driven |
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Auto 1 |
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Auto 2 |
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Auto 3 |
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Auto 4 |
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Auto 5 |
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Driver Information
Accidents |
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Full Name |
Drivers License # |
Age |
Sex |
Married |
Tickets |
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Non-Fault |
At - Fault |
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Driver 1 |
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Driver 2 |
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Driver 3 |
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Driver 4 |
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Driver 5 |
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Please List any tickets and accidents in the last 5 years |
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Desired Coverage Limits
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Bodily
Injury |
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Property Damage |
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Uninsured Motorist |
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Medical Coverage |
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Towing Coverage |
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Death Coverage
(Driver and Spouse) |
$15,000 coverage due
to death by an auto accident |
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Deductible's |
Collision |
Comprehensive
Rental Coverage |
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Auto 1 |
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Auto 2 |
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Auto 3 |
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Auto 4 |
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Auto 5 |
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Present Auto
Insurance Co. |
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Policy Expires (Month
/ Date) |
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Present Home
Insurance Co. |
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Policy Expires (Month
/ Date) |
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How were you referred |
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Comments / Request |
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Ask us about out Home /Auto
Discount! |
By
clicking the Submit button I have Reviewed the
Privacy Statement
and the Auto Insurance Disclosure Statement
and
Understand that this is only
a quote for the State of California, any
information and does
not constitute a binder of
coverage or proof of Insurance in any form, or does it guarantee
insurance. All Coverage's are subject to the
terms and
conditions contained in the policy
and endorsements. I agree the above
information is true and factual. Insurance will not
begin until I sign and make a down payment.
Please Read
Auto
Insurance Disclosure Statement below
This is not a binder or proof of Insurance.
Auto
Insurance Disclosure Statement
Please Read Below
Thank you for the opportunity to discuss your Auto insurance needs.
I look
Forward to
offering you the service and value that is
the standard of Ronn Hall Insurance. I am sure
you will see
hat this quote can affordable enhance your insurance program.
Please Note:
An Insured which refuses to Provide coverage to an applicant who is
a
“Good Driver” Must provide the applicant with a written
statement of the reasons it denied
coverage. In general, under
California law a “good driver” is a person who, during the last
three years, Has been continually licensed and has not had more than
one violation point or
more than One at-fault
accident resulting in only property damage.
As part of the
application process, Our Insurance Co. may collect personal information
from
Persons other than you or other individuals proposed for
coverage, including credit reports,
loss information reports
and motor vehicle reports.
This information, as well as other personal
or privileged
information subsequently collected by us, may in certain circumstances be
disclosed to third parties without your authorization.
You have a right of access and correction
with respect
to al personal information we collect. If you would like more detailed
information
in writing about our information collection
practices, please let us know
All coverage’s are subject to the Terms and conditions
contained in the policy and
endorsements.
The premiums shown are for a 6-month policy period.
If you have any questions please call me at the
Telephone number listed below.
coverage provided by *Ronn Hall Insurance Company main office Northbrook IL
Ask us about our Auto/ Home Discounts.
|
