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Automobile Insurance
General Questions
First Name:
Middle Name:
Last Name:
How Did You Hear About Us:
Birth Date (mm/dd/yyyy):
Marital Status:
Email:
Confirmemail:
Address (where You Live):
City:
State:
Zip Code:
Home Phone No:
Cell Phone No:
Fax No:
Driver's License Number:
Questions About Vehicle
Do You Currently Have Auto Insurance:
Policy Expiration Date:
Who Are You Currently Insured With:
Has Your Insurance Recently Lapsed:
Length With Previous Carrier:
Coverage Desired:
Body Injury Limit Desired:
Past Moving Violations:
Details About Tickets And/or Accidents:
Does Your Vehicle Have An Alarm?:
What Is The Primary Use:
Rate Your Own Credit:
Wheeldrive:
How Many Cylinders:
Vehicle Make:
Vehicle Model:
Year Built:
Vin #:
How Many Miles Do You Drive?:
Do You Own A Home Or Rent:
Gender:
Does You Car Have Air Bags:
How Long Have You Had Your License:
When Would You Like To Be Contacted:
Additional Vehicles
Vehicle 2: Vehicle Make:
Vehicle 2: Vehicle Model:
Vehicle 2: Year Built:
Vehicle 2: Vin #:
Vehicle 2: How Many Miles Do You Drive?:
Vehicle 2: What Is The Primary Use:
Vehicle 2: Does You Car Have Air Bags:
Vehicle 3: Vehicle Make:
Vehicle 3: Vehicle Model:
Vehicle 3: Year Built:
Vehicle 3: Vin #:
Vehicle 3: How Many Miles Do You Drive?:
Vehicle 3: What Is The Primary Use:
Vehicle 3: Does You Car Have Air Bags:
Additional Drivers
Driver 2: Name Of Additional Driver:
Driver 2: Birth Date (mm/dd/yyyy):
Driver 2: Past Moving Violations:
Driver 2: Past Accidents:

Driver 3: Name Of Additional Driver:
Driver 3: Birth Date (mm/dd/yyyy):
Driver 3: Past Moving Violations:
Driver 3: Past Accidents:

Driver 4: Name Of Additional Driver:
Driver 4: Birth Date (mm/dd/yyyy):
Driver 4: Past Moving Violations:
Driver 4: Past Accidents:
Comment:


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Corporate Office
11201 Washington Blvd.
Whittier, CA 90606
Tel: (866) 999-9AIS
(562) 692 0506
Fax: (562) 695-6665
Email: accuraterateais@yahoo.com
Website: www.accuraterateais.com