IF YOU WOULD LIKE AN AUTOMOBILE QUOTATION PLEASE COMPLETE THE FOLLOWING:

AUTO #1 Make Model Year Doors 2 door 4 door Anti-theft System No Yes ABS No Yes Air Bags No Yes     Address in Florida where garaged? How many months do you reside at this location? Permanently 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months

AUTO #2 Make Model Year Doors 2 door 4 door Anti-theft System No Yes ABS No Yes Air Bags No Yes     Location in Florida where garaged? How many months do you reside at this location? Permanently 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months

DRIVER #1 Date of Birth Do you drive the vehicle to work? No Yes If so, how many miles one-way? Occupation Any accidents of moving violations in the past 3 years? No Yes If accidents or violations, please explain To obtain a credit score, please enter your Social Security Number and Driver's License Number SSN: Driver's License #

DRIVER #2 NOTE If there are other drivers in the household, please enter their information here whether or not they will be driving the vehicle. Date of Birth Do you drive the vehicle to work? No Yes If so, how many miles one-way? Occupation Any accidents or moving violations in the past 3 years? No Yes If accidents or violations, please explain. To obtain a credit score, please enter your Social Security Number and Driver's License Number SSN: Driver's License #

COVERAGE What limits of liability would you like us to quote? 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 COMPREHENSIVE DED $250/500 COLLISION DED $250/500 Would you like an umbrella quotation providing an additional $1,000,000.00 coverage? No Yes Your Name Your Phone Number How would you like us to respond with your quote? Telephone Call Write via Snail Mail Write via Email If email, please provide us with your email address.

In order to provide an accurate quote, we must run a Credit Report and a Motor Vehicle report. All information is confidential and will only be used for quotation purposes. Yes you may run a Credit Report and Motor Vehicle report. No, do not run a Credit Report and Motor Vehicle report.

Copyright © The Johnsons Insurance All rights reserved.
13361 Overseas Highway, Marathon, Monroe, Florida 33050
Tel. 305-289-0213 / Fax: 305.743.1809

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