AUTO INSURANCE – Insure today... Be sure tomorrow

AUTO INSURANCE

Dalton Insurance Agency consistently saves our customers money on auto insurance. Complete the form below and see how much we can save you!

AUTO INSURANCE

Instructions:Please complete all parts of this form to the best of your ability so that we may provide and accurate quote for auto insurance.

GENERAL INFORMATION:

NAME: *
ADDRESS: *
Address Address Line 2 City State / Province / Region Postal / Zip Code Country
EMAIL: *
HOME PHONE:
WORK PHONE:
HOW SHOULD WE CONTACT YOU?
YOUR OCCUPATION:
YOUR EMPLOYER:
YEARS EMPLOYED:
CURRENT INSURANCE COMPANY:
HOW LONG HAVE YOU BEEN CONTINUOUSLY INSURED?
POLICY EXPIRATION DATE:
HOW LONG AT YOUR RESIDENCE?
DO YOU OWN YOUR HOME?
YES NO

DRIVER INFORMATION: (all drivers in your household must be listed)

DRIVER 1:

NAME:
LICENSE NUMBER:
DATE OF BIRTH:
GENDER:
MARITAL STATUS:
YEARS LICENSED:

DRIVER 2:

NAME:
LICENSE NUMBER:
DATE OF BIRTH:
GENDER:
MARITAL STATUS:
Years Licensed

DRIVER 3:

NAME:
LICENSE NUMBER:
DATE OF BIRTH:
GENDER:
MARITAL STATUS:
YEARS LICENSED:

DRIVER 4:

NAME:
LICENSE NUMBER:
DATE OF BIRTH:
GENDER:
MARITAL STATUS:
YEARS LICENSED:

ACCIDENT / VIOLATION / CLAIM HISTORY (past 3 years)

INSTRUCTIONS: Please include any claims, violations, accidents for the past 3 years so that we can accurately quote your policy.

INCIDENT 1:

DATE OF INCIDENT:
DRIVER INVOLVED:
INCIDENT TYPE:

INCIDENT 2:

DATE OF INCIDENT:
DRIVER INVOLVED:
INCIDENT TYPE:

INCIDENT 3:

DATE OF INCIDENT:
DRIVER INVOLVED:
INCIDENT TYPE:

INCIDENT 4:

DATE OF INCIDENT:
DRIVER INVOLVED:
INCIDENT TYPE:

VEHICLE INFORMATION:

INSTRUCTIONS:Please provide complete vehicle details for all vehicles to be included on this policy.

VEHICLE 1:

YEAR:
MAKE:
MODEL:
VEHICLE IDENTIFICATION NUMBER (VIN):
BODY TYPE:
USAGE:

VEHICLE 2:

YEAR:
MAKE:
MODEL:
VEHICLE IDENTIFICATION NUMBER (VIN):
BODY TYPE:
USAGE:

VEHICLE 3:

YEAR:
MAKE:
MODEL:
VEHICLE IDENTIFICATION NUMBER (VIN):
BODY TYPE:
USAGE:

VEHICLE 4:

YEAR:
MAKE:
MODEL:
VEHICLE IDENTIFICATION NUMBER (VIN):
BODY TYPE:
USAGE:

COVERAGE INFORMATION:

INSTRUCTIONS:In this section you may select your level of coverage for each vehicle on your policy.
BODILY INJURY (per person / per accident)
PROPERTY DAMAGE (per accident):
MEDICAL COVERAGE:
TOWING & LABOR:
EXTENDED TRANSPORTATION:

COMPREHENSIVE COVERAGE

VEHICLE 1:
VEHICLE 2:
VEHICLE 3:
VEHICLE 4:

COLLISION COVERAGE:

VEHICLE 1:
VEHICLE 2:
VEHICLE 3:
VEHICLE 4:
OTHER COVERAGE:

Verification

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