Automobile Quote Worksheet

Please print out and fax to 321.737.0952

Insurance Icon, Inc.

15 Hickory Street, Suite 206

Melbourne, FL 32904

Phone (321) 727-0951 Fax (321) 727-0952

General Information

Name

Street Address

City, State, Zip

Previous Address If Less Than 3 Years

City, State, Zip

Occupation

Employer

Employer Street Address

Employer City, State, Zip

Home Phone ( )

Present Auto Insurance Company

Current Premium

Work Phone ( )

Policy Expiration Date

Policy #

Do you own or rent? Own ____ Rent ____

Length at address

Vehicle – List all vehicles titled or leased to you or your spouse

Car #1

Car #2

Car #3

Year

Make

Year

Make

Year

Make

Model

Model

Model

Sub-Model (2dr Limited, 4dr, sport)

Sub-Model (2dr Limited, 4dr, sport)

Sub-Model (2dr Limited, 4dr, sport)

VIN #

VIN #

VIN #

Annual Mileage Driven

Odometer

Annual Mileage Driven

Odometer

Annual Mileage Driven

Odometer

Date Purchased

New Used

Date Purchased

New Used

Date Purchased

New Used

How car is Primarily Used ____ To and from Work or School Miles one way ______ Days per week ______ ____ Business Calls ____ Deliveries ____ Pleasure/Errands

How car is Primarily Used ____ To and from Work or School Miles one way ______ Days per week ______ ____ Business Calls ____ Deliveries ____ Pleasure/Errands

How car is Primarily Used ____ To and from Work or School Miles one way ______ Days per week ______ ____ Business Calls ____ Deliveries ____ Pleasure/Errands

Drivers – List all drivers in your household (Spouse must be listed)

Driver

1

Last Name

First Name

Initial

Birth Date

Sex

Marital Status

Social Security #

Drivers License #

License Issued Date

State Licensed Issued

2

Last Name

First Name

Initial

Birth Date

Sex

Marital Status

Social Security #

Drivers License #

License Issued Date

State Licensed Issued

3

Last Name

First Name

Initial

Birth Date

Sex

Marital Status

Social Security #

Drivers License #

License Issued Date

State Licensed Issued

Driving History – List all violations, accidents and losses

Violations in Past 5 Years

Accidents in Past 5 Years

Driver Number

Violation Date

Description (Speeding, stoplight, etc.)

Accident Date

Dollar amount & Description of Damage

Any Injuries?

At Fault?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Discounts – Check those that apply

Car #1 4-wheel anti-lock brakes Anti-theft device Driver’s side airbag Automatic Seat belts Passenger’s side air bags Vehicle garaged

Car #2 4-wheel anti-lock brakes Anti-theft device Driver’s side airbag Automatic Seat belts Passenger’s side air bags Vehicle garaged

Car #3 4-wheel anti-lock brakes Anti-theft device Driver’s side airbag Automatic Seat belts Passenger’s side air bags Vehicle garaged

Defensive Driver Course Driver #1 Driver #2 Driver #3 If Student, list grade point average : __________ Driver # ____

Coverage – Select Options

Bodily Injury Liability Limits – Same for all Vehicles (check one) 10/20 25/50 50/100 100/300 250/500 500/500

Property Damage Liability Limits – Same for all Vehicles (check one) 10,000 25,000 50,000 100,000 250,000

Comprehensive Deductible (check one)

Car #1 $100 $250 $500 $1,000 No Coverage Other $__________ Rental Car Coverage ________ Towing Coverage _______

Car #2 $100 $250 $500 $1,000 No Coverage Other $__________ Rental Car Coverage ________ Towing Coverage _______

Car #3 $100 $250 $500 $1,000 No Coverage Other $__________ Rental Car Coverage ________ Towing Coverage _______

Collision Deductible (check one)

Car #1 $100 $250 $500 $1,000 No Coverage Other $__________

Car #2 $100 $250 $500 $1,000 No Coverage Other $__________

Car #3 $100 $250 $500 $1,000 No Coverage Other $__________

Uninsured Motorists Coverage - (Optional coverage for bodily injury) Yes No Select coverage amount if you answered yes

25/50 50/100 100/300 250/500 500/500

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