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AUTOMOBILE INSURANCE QUOTE REQUEST

We would like to provide you with a free, no-obligation automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Name:  
Address:  
City:     State:    Zip: 
E-mail Address:  
Day Phone:     Evening Phone: 
Best Time To Call:  

CURRENT AUTO INSURANCE INFORMATION

Company Name (not agency):  
Policy Expiration Date:      Premium Amount:  $
Term:     6 months     1 year      Other

VEHICLE INFORMATION
Information in RED is required

CAR #1

Year:   Titleholder:  
Make:   Annual Miles:  
Model:   Air Bags?  
Body Style:   Security System?  
VIN:

Miles driven to school/work (one-way): 

If the vehicle is kept at another location, please specify below:
Location:  City:    State:  Zip: 

CAR #2

Year:   Titleholder:  
Make:   Annual Miles:  
Model:   Air Bags?  
Body Style:   Security System?  
VIN:

Miles driven to school/work (one-way): 

If the vehicle is kept at another location, please specify below:
Location:  City:    State:  Zip: 

LIABILITY LIMITS FOR ALL CARS
choose one:

Bodily Injury / Property Damage   Single Limit
  If Other, state limit:

OR


If "Other," please state Limit:

   If Other, state limit:  

DEDUCTIBLES / MISCELLANEOUS

Car # Comprehensive Collision Towing Loss of Use
1   Yes   Yes
2   Yes   Yes

DRIVER INFORMATION
Please list all drivers in household
Information in RED is required

Driver #1

Name:   Relationship to you:  
DL #:   Marital Status:  
State:     Years Licensed:  Courses completed last three years:
DOB:   (mm/dd/yyyy) Driver's Education   Yes   No
Sex:   Accident Prevention   Yes   No

Driver #2

Name:   Relationship to you:  
DL #:   Marital Status:  
State:     Years Licensed:  Courses completed last three years:
DOB:   (mm/dd/yyyy) Driver's Education   Yes   No
Sex:   Accident Prevention   Yes   No

DRIVER HISTORY
In the space provided below, please give details to all:
moving violations
license suspensions/revocations
DUI convictions
accidents
 in the last three (3) years, including:
Driver, date of violation, type of violation, fine(s), and speed over posted limit
(If describing an accident, please disclose the total damages, injuries, and who was at-fault)

ADDITIONAL COMMENTS
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc., please enter them here.

    

 
PERSONAL LINES DEPARTMENT EXTENSION E-MAIL ADDRESS
Sandi Schwandt, CISR 135 sandis@generalsouthwest.com
Garry King, CISR 125 garryk@generalsouthwest.com
Michelle Fischer, CISR 128 michellef@generalsouthwest.com
Tara Munson 130 taram@generalsouthwest.com
     
5628 East Thomas ~ Phoenix, Arizona 85018 ~ 480-990-1900 ~ FAX: 480-481-9551
joeb@generalsouthwest.com ~ US Postal Address: P. O. Box 98 Scottsdale, Arizona 85252