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Combined Quote Form

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30 views2 pages

Combined Quote Form

Uploaded by

Al
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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auto/property

Auto/Property Quote Form


This is a request for a quotation for automobile and property insurance. It is not an application for insurance.
To expedite your quote, please provide the following information.

Name: Date of Birth:


Address: City: State: Zip:
Phone: Best time to call: morning afternoon evening
Email:

Automobile:
Vehicle Year Make Model One-Way Commute/Annual Mileage Business Use (Yes/No)
1.
2.
3.

Drivers in Household:
Name Date of Birth Married/Single Relationship to you License #
1.
2.
3.

Driving history (past 5 years)


Has any driver had his/her license suspended or revoked? Yes No
If yes, please explain who, when and why:

Any accident or motor vehicle convictions in the past five years whether you or someone else was at fault?
Please list driver, date of incident and type of incident.

List all fire, theft, glass and/or vandalism losses.

Present Insurance Co.: Expiration Date: Annual Premium: $


Current Liability Limits:

This is not an application for insurance. This form is only an attempt to gather some of the information necessary
to process your quote, and actual information used will vary by state.

As allowed by law, we will ask for credit and other consumer reports from consumer reporting agencies concerning
your application for insurance or any renewal of insurance. These may include driving records, claim history reports
and credit based insurance score.
Property:
Home Yr. Built: Style/Number of stories:
Built-in Garage
Condominium or Co-op
Renters (Please check one)
Month/Year of Purchase:
Is the Home a Primary Residence Secondary Residence
Number of months not occupied in a year:
Number of mortgages:
Construction: Wood Exterior Brick Veneer Solid Brick/Masonry Aluminum/Vinyl Siding
Log Home Manufactured Home
Roof Covering Type: Asphalt Shingles Tiles/Slate Steel Other:
Primary Source of Heat: Oil Gas Electric Other:
Alternative Source of Heat: Wood/Coal/Pellet Stove Space Heater Other:
Feet from hydrant: Miles to fire station:
Protection Devices: Smoke Detector Fire Extinguisher Dead Bolt Locks Monitored Fire Alarm
Monitored Burglar Alarm
Present Insurance Co.: Expiration Date:
Current Coverage Amt: $
Any losses in the last five years? If yes, please explain:

Please check here if you are interested in more information about:


Personal Article Floater (jewelry, furs, fine arts, etc.) Boat/Yacht Insurance
Personal Umbrella Liability Protection Flood Insurance
Replacement Cost Estimate of your home Special Programs for employee, association or affinity groups

Thank you for your interest in Travelers.

The Travelers Indemnity Company and its property casualty affiliates,


One Tower Square, Hartford, CT 06183
travelers.com © 2009 The Travelers Companies, Inc. All rights reserved. PL-14194 New 6-09

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