J and L Insurance | Automobile Insurance

Automobile Insurance Quote Information Form

Please fill out this form to give us the opportunity to give you the best quote for your automobile(s).

General Information First Name:
Last Name:
Street Address:
Unit/Apt No.
City:
State:
Zip Code:
Home Telephone:
Mobile/Business Telephone:
Email:

Date of Birth - MM-DD-YYYY:
Driver's Licence Number:
State of Issue:
Have you had ANY claims or accidents in the past 5 years?
Prior or Current Insurance Co.
Has insured maintained continuous coverage? Yes No
Prior Bodily/Injury Liability Limits?
Date Insurance Expires: (MM-DD-YYYY)

Vehicles:

Vehicle 1 Information: Make:
Model:
Year:
Vehicle ID Number:

Door Style:

Version - ie. RS,LS,GT:

Airbags:

Antilock Brakes:

Factory Installed Alarm:

Tracking Device (ie LoJack/Onstar):

Miles Driven, One Way to Work/School:

Vehicle also used for Business? Yes No

If Yes, Business Miles Per Day:

Vehicle 2 Information: Make:
Model:
Year:
Vehicle ID Number:

Door Style:

Version - ie. RS,LS,GT:

Airbags:

Antilock Brakes:

Factory Installed Alarm:

Tracking Device (ie LoJack/Onstar):

Miles Driven, One Way to Work/School:

Vehicle also used for Business? Yes No

If Yes, Business Miles Per Day:

Coverage Amount

Bodily Injury & Liability Coverage Information:

Bodily Injury & Liability coverage will cover you if you injure someone or damage another's property with your vehicle.

Amounts are expressed with three figures and represent thousand dollar amounts:

Bodily Injury Per Person / Bodily Injury Per Accident / Property Damage Per Accident.

Select Coverage Amounts:

Unininsured Motorist Coverage Information:

Uninsured Motorist coverage protects you if someone else hits you and has no insurance or not enough to cover your injuries. Although coverage is optional, you have the option to carry coverage equal to or less than what you have in your bodily injury coverages.

Amounts are expressed with two figures and represent thousand dollar amounts:

Bodily Injury Per Person / Bodily Injury Per Accident

Select Coverage Amounts:

Comprehensive and Collision Coverage Information:

Collision Insurance covers your vehicle if it is damaged in a collision. Comprehensive Insurance covers the vehicle for theft and for damage caused by anything other than collision. (eg: vandalism, storm damage, fire.)

Amounts are expressed with two figures and represent dollar amounts of your deductible:

Comprehensive Deductible / Collision Deductible

Select Coverage Amounts: