Florida Chartered Insurance Group Excess Liability

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Auto Quote Form

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Call our Auto Specialists at 1-888-267-1733

Personal Information

Please fill out all applicable fields. Please fill out all applicable fields. The more information our underwriters have, the more accurate your quote will be.
*First Name:
Middle Initial:
*Last Name:
*Street:
Apt:
*City:
State:
*Zip Code:
Home Phone:	( ) -
Work Phone:	( ) -
Fax:	( ) -
Referred By
*Email:
How did you hear about us?
How would you prefer to be contacted?	Phone Fax Email Snail mail

Insurance History

Do you have current insurance?	Yes No
If yes, please answer the following:
Who is your current insurance carrier?
How many continuous years have you had auto insurance?	1 2 3 4 5
What are your current limits?	10/20 25/50 50/100 100/300 250/500

Drivers

Driver 1
*First Name:		Relation:
Middle Initial:		Occupation:
*Last Name:		Currently licensed?	Yes No
Gender:	Male Female	If yes, what is your Drivers License number?
Social Security Number: (optional) Why?		*Date of Birth: (mm) (dd) (yyyy)

Driver 2 (optional)
*First Name:		Relation:
Middle Initial:		Occupation:
*Last Name:		Currently licensed?	Yes No
Gender:	Male Female	If yes, what is your Drivers License number?
Social Security Number: (optional) Why?		Date of Birth: (mm) (dd) (yyyy)

Driver 3 (optional)
*First Name:		Relation:
Middle Initial:		Occupation:
*Last Name:		Currently licensed?	Yes No
Gender:	Male Female	If yes, what is your Drivers License number?
Social Security Number: (optional) Why?		Date of Birth: (mm) (dd) (yyyy)

Driver 4 (optional)
*First Name:		Relation:
Middle Initial:		Occupation:
*Last Name:		Currently licensed?	Yes No
Gender:	Male Female	If yes, what is your Drivers License number?
Social Security Number: (optional) Why?		Date of Birth: (mm) (dd) (yyyy)

If you have more Drivers to add, please contact us.

Tickets, Accidents, Violations, & Claims

Please list any tickets, accidents, violations, or claims made in the past 5 years. If none, please continue skip.
Date of violation/claim:	Description:	Driver Name:
(mm) (dd) (yyyy)
(mm) (dd) (yyyy)
(mm) (dd) (yyyy)
(mm) (dd) (yyyy)
(mm) (dd) (yyyy)
If there are more tickets, etc. please list in remarks section at end of quote.

Vehicle

Vehicle 1
*Year:		Door Count:
*Make:		Cylinders:
*Model:		Please Choose:
Sub-model: Help?		Comprehensive:
Vehicle Identification Number: Help?		Collision:

Vehicle 2 (optional)
*Year:		Door Count:
*Make:		Cylinders:
*Model:		Please Choose:
Sub-model: Help?		Comprehensive:
Vehicle Identification Number: Help?		Collision:

Vehicle 3 (optional)
*Year:		Door Count:
*Make:		Cylinders:
*Model:		Please Choose:
Sub-model: Help?		Comprehensive:
Vehicle Identification Number: Help?		Collision:

Vehicle 4 (optional)
*Year:		Door Count:
*Make:		Cylinders:
*Model:		Please Choose:
Sub-model: Help?		Comprehensive:
Vehicle Identification Number: Help?		Collision:

If you have more Vehicles to add, please contact us.

Coverage

*Bodily Injury:	10,000/20,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000
*Property Damage:	10,000 25,000 50,000 100,000
Personal Injury Protection:	$10,000 with $0 deductible.
Uninsured Motorist:	10,000/20,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 None
Medical Payments:	1,000 2,000 2,500 5,000 10,000 None
Rental Reimbursement:	Yes No
Towing & Labor:	Yes No
Remarks: