OUR MISSION:
We pledge to help you find
the most competitive auto
insurance rate possible,
and the best coverage
for your insuranc dollar.
Our agency offers low cost Florida auto insurance with
highly qualified professionals
committed to help you get the
best coverage and price for your Florida Auto Insurance.
Call now or complete the
online form to see how much
money you can save on your Florida auto insurance.
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
If YES to SR22 filing, why needed? (list accident/cite)
Give details on all violations or accidents:
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS: If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:
VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible:
Rental Car & Towing Coverage?
YES
NO
Uninsured Motorists Coverage?
YES
NO
Medical Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits
- - - Liability Limits Must Match Vehicle #1 - - -
Select Comprehensive Deductible:
Select Collision Deductible:
Rental Car & Towing Coverage?
YES
NO
Uninsured Motorists Coverage?
YES
NO
Medical Coverage?
YES
NO
Comments or Remarks:
(List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:
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