Automobile Quote

McKINNEY INSURANCE GROUP

General Information


Address
City:	State: ZIP:
County:	Email:
Phone Day:	( ) - Night: ( ) -
Best time to call:	AM PM Respond by: Email or Phone Call?

Current Auto Insurance Company (not agency):

Company Name:
Policy Exp. Date:	/ /
Term:	6 Months 1 Year Other

Vehicle Information:

(include all cars you or your family members own or lease)

Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)

Annual Mileage
Business Use?
Yes No Drive to work? Yes No
# of miles (one way):
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
4-Wheel Drive?
Yes No
Anti-lock Brakes?
Yes No

If vehicle is kept at an address other than that listed above, please indicate:
Location City: State: Zip:

Vehicle Information:

(include all cars you or your family members own or lease)

Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)

Annual Mileage
Business Use?
Yes No Drive to work? Yes No
# of miles (one way):
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
4-Wheel Drive?
Yes No
Anti-lock Brakes?
Yes No

If vehicle is kept at an address other than that listed above, please indicate:
Location City: State: Zip:

Vehicle Information:

(include all cars you or your family members own or lease)

Car #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)

Annual Mileage
Business Use?
Yes No Drive to work? Yes No
# of miles (one way):
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
4-Wheel Drive?
Yes No
Anti-lock Brakes?
Yes No

If vehicle is kept at an address other than that listed above, please indicate:
Location City: State: Zip:

Driver Information:

(including all licensed drivers in your household)

Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Completed		# of Yrs. Licensed
Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Drivers Education Course	Accident Prevention Course	# of Yrs. Licensed
		Self		M F	M S	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N

Driver History

If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
Yes No
If yes, please answer the following:

Driver	Date	Type of Conviction
	//
	//
	//
	//

2. Have you had any claims and/or accidents, regardless of fault, over the past 3 years?
Yes No
If yes, please answer the following:

Driver	Date	Injuries	At Fault	Description
	//	Y N	Y N
	//	Y N	Y N
	//	Y N	Y N
	//	Y N	Y N

Liability Limit for All Cars:

Choose either Bodily Injury & Property Damage

Bodily Injury	Property Damage

OR Single Limit

Single Limit

Uninsured Motorist Coverage for All Cars:

Choose either Bodily Injury & Property Damage

Bodily Injury	Property Damage

OR Single Limit

Single Limit

Medical Payments or Personal Injury Protection:

Please select the amount of coverage for medical payments:

Deductibles and Additional Coverage:

	Deductible - Comprehensive	Deductible - Collision	Towing	Rental
Car #1			Yes	Yes
Car #2			Yes	Yes
Car #3			Yes	Yes

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this automobile quote form. One of our representatives will respond to your submission as soon as possible!

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