Dave McChesney
Agency

1798 East Route 66
Flagstaff, AZ 86004
520-774-3553 Fax: 520-774-9020
1-800-734-7940

AUTO QUOTE FORM

Please note: If you prefer not to complete this form, you may obtain a quote by faxing your current automobile declaration page to 520-774-9020

PERSONAL INFORMATION

Name:
Address:
City:
County:
State:	Arizona
Zip Code:
E-Mail Address:
Phone Number
Fax Number
Current Insurance Company:
Expiration Date:
Policy #

DRIVER INFORMATION

Driver 1

Driver 1 Name:
Driver 1 Occupation:
Driver 1 Date of Birth:
Driver 1 Sex:

Driver 2

Driver 2 Name:
Driver 2 Occupation:
Driver 2 Date of Birth:
Driver 2 Sex:

Driver 3

Driver 3 Name:
Driver 3 Occupation:
Driver 3 Date of Birth:
Driver 3 Sex:

Driver 4

Driver 4 Name:
Driver 4 Occupation:
Driver 4 Date of Birth:
Driver 4 Sex:

Have any of the above listed drivers had any accidents or moving violations in the past 3 years?

If you answered yes to the above question, please fill in the DATE, DRIVER NAME and DESCRIPTION of violation and or accident in the text box below.

VEHICLE INFORMATION

	Year	Make	Model	#of doors	Principle Driver (1,2,3or4)	Airbags	Anti-lock Brakes
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4

COVERAGE INFORMATION

Liability Limits

Please choose a liability limit & property damage limit from the limits listed below. Limits will be the same for all vehicles.

UnInsured/UnderInsured Motorist Protection

Please check if you desire Un/UnderInsured Motorist Coverage. Please note that limit for Un/UnderInsured Motorist Protection will be the same as the liability limit you selected above. If you do not desire this coverage, a rejection form must be signed.

Personal Injury Protection/Medical Payments

Please check if you would like Prime Provider Personal Injury Coverage/Medical Payments.

Comprehensive Coverage

Comprehensive Covers your vehicle for: Hail, Fire, Theft, Animal Collision and other losses not covered by Collision.

Vehicle 1

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 2

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 3

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 4

Comprehensive Coverage If Yes, Choose Deductible

Collision Coverage

Collision Covers damage to your vehicle if you're in an accident and its your fault.

Vehicle 1

Collision Coverage If Yes, Choose Deductible

Vehicle 2

Collision Coverage If Yes, Choose Deductible

Vehicle 3

Collision Coverage If Yes, Choose Deductible

Vehicle 4

Collision Coverage If Yes, Choose Deductible

Towing Coverage

Do you desire Towing Coverage

Rental Coverage

Do you desire Rental Coverage

Thank you for completing our online quote form. We will respond with a quote within two business days.

THANK YOU!!

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