Auto Quoting Form For Eland Agency Disclaimer: Please note :Submitting this following information is not a request or application for coverage. Coverage can only be bound be signing and completing an application and submitting the application to the agent. This is an estimate based on the information that you provide. It is for comparison pricing only and should not be considered as an offer for insurance.
Contact Information
Name
Address 1
Address 2
City, State, Zip
Home Phone
Email Address
How would you like to be contacted? Phone Email Mail
Liability Limits
25/50 50/100 100/300 300/500 500/1000 Bodily Injury (in Thousands)
25000 50000 100000 250000 300000 Property Damage
500 1000 2000 5000 10000 25000 Medical Payments
25/50 50/100 100/300 300/500 500/1000 Underinsured Motorist (in Thousands)
25/50 50/100 100/300 300/500 500/1000 Uninsured Motorist (in Thousands)
Driver Information
Driver No 1 Full Name
Date of Birth
SSN (Required for Verified MVR)
Occupation & Location of Work
Describe Violations or accidents last 5 yrs
Driver No 2 Full Name
Driver No 3 Full Name
Driver No 4 Full Name
Driver No 5 Full Name
Vehicle Information
Year Vehicle 1
Make & Model (i.e... Ford Escort LS)
Vehicle Identification Number
Work Pleasure Business Student at School Farm Usage
Driver #
No Comprehensive 0 Ded 50 Ded 100 Ded 200 Ded 250 Ded 500 Ded Comprehensive
No Collision 0 Ded 50 Ded 100 Ded 250 Ded 500 Ded 1000 Ded Collision
Year Vehicle 2
Year Vehicle 3
Year Vehicle 4
Year Vehicle 5
Additional Comments