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Plaza Insurance: Automobile Insurance Request Form

In order to receive preliminary insurance and initial quote information please fill and send in the following form. Thank you!


NAME / DATE OF BIRTH / YEARS LICENSED

GARAGE ADDRESS

CITY STATE ZIP

MALE FEMALE MARRIED SINGLE

ADDITIONAL DRIVER INFORMATION
NAME / DATE OF BIRTH / YEARS LICENSED

ARE YOU CURRENTLY INSURED?
Yes
No

YEAR / MAKE / MODEL / ANNUAL MILEAGE (est.) / VEHICLE USE

MOTOR VEHICLE RECORD (last 3 years)

 

COVERAGE / LIMITS DESIRED Please check where applicable.
Bodily Injury Liability
Limit of liability

Property Damage Liability
Limit of liability

Medical Payments
Limit of liability

Uninsured / Motorists Bodily Injury / Underinsured
Limit of liability

Uninsured Motorist Property Damage


Comprehensive Deductibles
Deductible


Collision Deductibles
Deductible

Towing
Rental Reimbursement
Waiver of Collision Deductible

Do you have more than one vehicle? If so, please proceed. If not, click here.


YEAR / MAKE / MODEL / ANNUAL MILEAGE (est.) / VEHICLE USE

MOTOR VEHICLE RECORD (last 3 years)

 

COVERAGE / LIMITS DESIRED Please check where applicable.
Bodily Injury Liability
Limit of liability

Property Damage Liability
Limit of liability

Medical Payments
Limit of liability

Uninsured / Motorists Bodily Injury / Underinsured
Limit of liability

Uninsured Motorist Property Damage


Comprehensive Deductibles
Deductible


Collision Deductibles
Deductible

Towing
Rental Reimbursement
Waiver of Collision Deductible

General Comments / Additional Questions

How did you first discover or learn about us?

Please contact me by:

Email


Phone
If you'd like to be contacted by phone, please indicate the best time for us to call. BETWEEN


Fax


Mail Address

Thank you for your time! - Plaza Insurance Sales, Inc.