Personal Automobile Insurance Quote (All of the information is only used for quoting purposes)

Driver Information (List All Drivers Under your Roof)

First Name of Registered Owner     Middle Initial  

Last Name        Sex : Male Female

Email Address:

Home Phone Number ()- - 

Work Phone Number  ()- -

Cell Phone Number    () - -                                                                                                                                             

Is Primary Driver  Yes No                                                                                 

Date of Birth (mm/dd/yy)                                                                                                      

Social Security Number  Drivers Lic #   State  AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY

Driving History  :  

Have you had any tickets or Accident s in the past 3 years                                                                                                                                                                                                                                                        

Yes  No                                                                                                                                                                                                                                     

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other

Resulting in Accident Yes No   

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other

Resulting in Accident Yes No              

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other

Resulting in Accident Yes No  

Date (mm/dd/yy)  Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other

 Resulting in Accident Yes No  

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other

Resulting in Accident Yes No

2nd Driver Information

2nd Reg. Owner or Driver's First Name    Middle Initial Last Name   Relationship Spouse Child Fiance Roommate (Other)  

Is Primary Driver Yes  No      Date of Birth (mm/dd/yy)     

Social Security Number  Drivers Lic #   State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY

Driving History  :  

Have you had any tickets or Accident s in the past 3 years                                                                                                                                                                

YesNo                                                                                                                                                                                                                                                  

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

3rd Driver Information

Driver's First Name         Middle Initial        Last Name       Relationship Spouse Child Fiance Roommate (Other)                               

Is Primary Driver Yes  No         Date of Birth (mm/dd/yy)     

Social Security Number  Drivers Lic #   State  AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY

Driving History  :  

Have you had any tickets or Accident s in the past 3 years  

Yes  No  

 Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

4th Driver Information

Driver's First Name         Middle Initial        Last Name        Relationship Spouse Child Fiance Roommate (Other)

Is Primary Driver Yes  No         Date of Birth (mm/dd/yy)     

Social Security Number  Drivers Lic #   State  AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY

Driving History  :  

Have you had any tickets or Accident s in the past 3 years  

Yes  No                                                                                                                                                                                                

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Date (mm/dd/yy)   Offense -none- Speeding - less than 15 over Speeding - more than 15 over Careless Driving Reckless Driving - DUI Reduced Reckless Driving Failure to yeild Failure to obey a traffic device Improper lane change Improper start DUI DUI - with property damage DUI - with injury Vehicular manslaughter other  

Resulting in Accident Yes No

Addresses                                                                                                                                                                                                                                 

Garaging Address   Garaging City        Garaging State  AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY      Zip Code     County Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St.Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington                      Mailing Address          Mailing City         Mailing State  AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY      Zip Code     County Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St.Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington

Liability Coverage  (Must be the Same on All Vehicles)

Bodily Injury Liability Limits  -None- $10,000 per person / $20,000 per accident $25,000 per person / $50,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident

Property Damage Liability $10,000 $25,000 $50,000 $100,000 $250,000

Personal Injury Protection with a Deductible of -None- $250 $500 $1,000

Uninsured Motorist Coverage -None- $10,000 per person / $20,000 per accident $25,000 per person / $50,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident

Non-Stacked Uninsured Motorist Coverage  Yes No

Medical Payments -None- $500 $1000 $2500 $5000

Physical Damage Coverage

Comprehensive Coverage Deductible -No Coverage- $250 $500 $1000 $1500

Collision Coverage Deductible      -No Coverage- $250 $500 $1000 $1500

Automobiles

Vehicle 1 - Year  Make None Acura Alfa Romero Audi Austin Healey Austin Martin Avanti Bentley BMW Buick Cadillac Cheverolet Chrysler Citreon Cort Daiwoo Delorian Dodge Eagle Fiat Ferrarri Ford Geo GMC Honda Hummer Hyundai Infinity Isuzu Jaguar Jeep Kia Lamborgini Lancia Land Rover Lexus Lincoln Lotus Masaratti Mazda McClaren Mercedes Mercury MGB Mitsubishi Nissan Oldsmobile Pantara / DeTomoso Peugot Plymouth Pontiac Porche Renault Rolls Royce SAAB Saturn Studebaker Suburu Suzuki Toyota Truimph Volkswagon Volvo Yugo -Other-   Model Vehicle ID Number 

Vehicle 2 - Year  Make Acura None Alfa Romero Audi Austin Healey Austin Martin Avanti Bentley BMW Buick Cadillac Cheverolet Chrysler Citreon Cort Daiwoo Delorian Dodge Eagle Fiat Ferrarri Ford Geo GMC Honda Hummer Hyundai Infinity Isuzu Jaguar Jeep Kia Lamborgini Lancia Land Rover Lexus Lincoln Lotus Masaratti Mazda McClaren Mercedes Mercury MGB Mitsubishi Nissan Oldsmobile Pantara / DeTomoso Peugot Plymouth Pontiac Porche Renault Rolls Royce SAAB Saturn Studebaker Suburu Suzuki Toyota Truimph Volkswagon Volvo Yugo -Other-   Model Vehicle ID Number 

Vehicle 3 - Year  Make None Acura Alfa Romero Audi Austin Healey Austin Martin Avanti Bentley BMW Buick Cadillac Cheverolet Chrysler Citreon Cort Daiwoo Delorian Dodge Eagle Fiat Ferrarri Ford Geo GMC Honda Hummer Hyundai Infinity Isuzu Jaguar Jeep Kia Lamborgini Lancia Land Rover Lexus Lincoln Lotus Masaratti Mazda McClaren Mercedes Mercury MGB Mitsubishi Nissan Oldsmobile Pantara / DeTomoso Peugot Plymouth Pontiac Porche Renault Rolls Royce SAAB Saturn Studebaker Suburu Suzuki Toyota Truimph Volkswagon Volvo Yugo -Other-   Model Vehicle ID Number 

Vehicle 4 - Year  Make None Acura Alfa Romero Audi Austin Healey Austin Martin Avanti Bentley BMW Buick Cadillac Cheverolet Chrysler Citreon Cort Daiwoo Delorian Dodge Eagle Fiat Ferrarri Ford Geo GMC Honda Hummer Hyundai Infinity Isuzu Jaguar Jeep Kia Lamborgini Lancia Land Rover Lexus Lincoln Lotus Masaratti Mazda McClaren Mercedes Mercury MGB Mitsubishi Nissan Oldsmobile Pantara / DeTomoso Peugot Plymouth Pontiac Porche Renault Rolls Royce SAAB Saturn Studebaker Suburu Suzuki Toyota Truimph Volkswagon Volvo Yugo -Other-   Model Vehicle ID Number 

Additional Information 

Do you own a home or condominium? No Yes

Are you a Full Time Student at College, High School, or Trade School ? No Yes

Have you had the type of coverage that you are applying for with in the last 60 days for a period of 6 months or more? No Yes

If the answer to the last question is yes, Who have you had prior with ?     For How Long ? Not Applicable Less than 6 months 6mo to 1 year 1yr to 3 yr 3yrs or more

Has there been a lapse in coverage ? yes no    If there has been a lapse, for how long? 1 day 2-5 days 5-10 days 10-30 days more than 30 days, less than 45 days more than 45 days

Is there any un repaired damage on any auto that you are requesting coverage on ? no yes

Is any of the vehicles used for business, have advertising on the vehicle, or used to carry tools or equipment to and from the job site? no yes

*In the rating of your automobile coverage, some of the carriers that we use will check your credit score. This is considered a "Soft" inquiry, and will not affect your credit rating. Your information is not shared with anyone, other than the insurance carriers that we are using to rate your policy. Please feel free to contact our agency at 800-763-6118 for a full disclosure of our credit policy or those of our insurance carriers. By completing this form you are allowing us to utilize your credit score to procure a better possible rate for your automobile insurance.

**Florida Direct Insurance Agency will not pull your Motor Vehicle Report (MVR) until we have agreed to write your policy, please be as accurate as possible as to your ticket(s) in the past three years. That is all we will be going back for our companies. In the event you have more tickets on your license than you have stated on this form, then the rate can and will go up respectively. If you know you have some tickets, but are unsure what they are, please feel free to call our offices and make prior arrangements to pull your MVR at 800-763-6118.