Wasserman Agency - Get a quote for auto insurance today!

Personal and contact information: This information should relate to the individual most likely filling out this form otherwise hoi will be responsible for managing and paying for this policy if and when it is established.
Name:
Street Address:
City State Zip
County:
Main Phone:
Work Phone:
Cell Phone:
email:
Best Contact Time:
Current Coverage: For a more accurate quotation please make sure to provide all of the following information if you currently do have insurance. If not please indicate that using the following drop-down:
select:
Bodily Injury:
Medical:
Property Damage:
Uninsured Motorist/Under-insured Motorist:
Tort coverage:
Primary Drivers: Please list the following details for the vehicles insured primary driver. If you are listing multiple vehicles this could be head of household or either parties who will be primary drivers or either vehicles.
Primary Driver name:
Married? Date-of-birth Drivers License: State
Accidents or Violations: For the primary driver and any following drivers to be included on your policy(ies) it is important that you note any accidents or traffic violations which have occurred within the past three years**. Please be detailed and include dates and anything which may be material to these incidents. Note if a traffic infraction is moving (ie. speeding) or standing (ie. parking violation) and be as detailed as you can regarding accident descriptions.
Driver #1 ** Accidents or Violations
Additional Licensed Household Drivers: It is legally required in most states that all licensed drivers in a household are listed to insurance policies. This includes all family members licensed to drive motor vehicles living in the household or other non-family members who are likely to be driving the insured vehicle. If you are only insuring 1 driver do not fill in the section, only address drivers who do apply. Date-of-birth is mandatory for any listed drivers. If your policy will only cover one driver, please proceed to vehicles.*
Driver #2
Relationship: Date-of-birth* Drivers License: State
Driver #2 *Accidents or violations:
Driver #3
Relationship: Date-of-birth* Drivers License: State
Driver #3 *Accidents or violations:
Driver #4
Relationship: Date-of-birth* Drivers License: State
Driver #4 *Accidents or violations:
Driver #5
Relationship: Date-of-birth* Drivers License: State
Driver #5 *Accidents or violations:
	Please indicate if there are additional drivers to be covered and if so, how many. Indicates the number of drivers beyond the fifth driver.
Use this "Additional Comments" area if you have additional information about additional drivers beyond the first five or if you simply wish to provide specific details about any of the drivers you have not yet indicated.
Additional Driver Comments
Insured Vehicles: Please list all vehicles to be insured under this policy. Describe vehicle by make(ie. Chevrolet or Subaru), year, and style (ie. Impala or Legacy) List all of the vehicles which will be covered under your policy. If your policy will need to cover more than four vehicles you can contact us by phone, or email or use "additional Information" area within "Insured Vehicles" to provide additional vehicle descriptions.
Vehicle 1:
Year Make Style
VIN#:
Deductibles: Comprehensive Collision If your policy will only cover 1 vehicle, proceed to complete request.
Vehicle 2:
Year Make Style
VIN#:
Deductibles: Comprehensive Collision
Vehicle 3:
Year Make Style
VIN#:
Deductibles: Comprehensive Collision
Vehicle 4:
Year Make Style
VIN#:
Deductibles: Comprehensive Collision
	Please indicate if there are additional vehicles to be covered and if so, how many.
Use this "Additional Vehicle Comments" area if you have additional information about additional drivers beyond the first five or if you simply wish to provide specific details about any of the drivers you have not yet indicated.
Additional Vehicle Comments
This form will NOT PROCESS properly if you do not indicate agreement to the terms listed and add your initials below. When you click the button below indicating to submit your request, if you do not arrive at a page indicating your request has been submitted, please note details and click your back button to review the form and correct and omissions. If you are not sure that your request has been sent, please call us to confirm.
Terms & Conditions, please check and initialize or form will NOT process.	Please place a check mark (click on) the box to the left of this text to indicate that you understand the following terms and conditions. As the individual filling out this form you understand that this is only a request for a quotation for your automotive insurance policy. Submitting this form does NOT constitute or imply that you have purchased vehicle coverage from the Wasserman Agency or any of its affiliates. As the individual filling out this form you also confirm that you understand you are legally obligated to provide all information requested to the best of your ability, that all information is correct, and current to your knowledge and ability to know at the time you are submitting this form. DISCLOSURE: Where permitted by law, some insurance companies may confirm your information, through the use of consumer reports, which may include credit score and driving record. By submitting this information, I request that the Wasserman Agency contact me via email, telephone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to provide quotes.
Initials	<< Please place your initials here.