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AUTOMOBILE QUOTE

THE DECISIVE DIFFERENCE INC. (315)433-1180

Driver's Name's
D.O.B
License #'s
SSN
Marital
Status
Yrs Licensed

  Home Address:

Name  
Title  
Company  
Address  
Address2  
City  
State, Zip  
Telephone  
Fax  
E-mail  

Driving Record: (All drivers) Tickets/Accidents 3 years (Including NAF), Comprehensive claims, Also Major Violations 10 Years (DWI, Reckless Driving, etc.). Type in None if None:
Driver
Date
 Offense

  Credits Driver 1:
 
ABS:
Yes  No
    
Air Bags:
Yes  No
   
Alarm:
Yes  No
Active or Passive: (active must be armed by you/passive automatically arms itself)
Automatic Seat Belts:
Yes  No
   
Defensive Driving Course:
Yes  No
(within past 3 years)  

  Credits Driver 2:
 
ABS:
Yes  No
   
Air Bags:
Yes  No
   
Alarm:
Yes  No
Active or Passive: (active must be armed by you/passive automatically arms itself)
Automatic Seat Belts:
Yes  No
   
Defensive Driving Course:
Yes  No
(within past 3 years)  

  Credits Driver 3:
 
ABS:
Yes  No
   
Air Bags:
Yes  No
   
Alarm:
Yes  No
Active or Passive: (active must be armed by you/passive automatically arms itself)
Automatic Seat Belts:
Yes  No
   
Defensive Driving Course:
Yes  No
(within past 3 years)  

  Use of Vehicle:
Business Pleasure Work
Mileage one way:
Business Pleasure Work
Mileage one way:
Business Pleasure Work
Mileage one way:

  Coverages:
Liability:
PIP:
Sum:
Comprehensive: Yes  No Yes  No Yes  No
  Deductible: Deductible: Deductible:
Collision: Yes  No  Yes  No    Yes  No   
  Deductible: Deductible: Deductible:
Medical:
Towing: Yes  No  Yes  No  Yes  No 
Rental: Yes  No  Yes  No  Yes  No 

Present Carrier Name:
Present Carrier Premium:
Problems with Personal Credit:
©2009 Checks & Balance