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<td > Driver Number

Auto :

Automobiles today are expensive. Without a comprehensive insurance program, you could face substantial losses. Auto insurance is more than a matter of insuring your vehicle for loss or repairs after an accident. It is a financial safety net that can help you offset the cost of:

  • Bodily injuries to yourself or others
  • Lost wages due to injury
  • Benefits to survivors when an accident results in death
  • Lawsuits brought against you as the result of an accident
  • Repairs made to your auto due to damage caused in an accident.

You select a package of insurance from standard types of coverage - a package that will protect you, your family, your vehicle and your assets. Your particular package could include:

  • Bodily Injury Liability
  • Property Damage Liability
  • Collision Coverage
  • Comprehensive Coverage
  • Medical Payments Coverage
  • Uninsured/Underinsured Motorist Protection
The insurance premium for your car depends on the following:
-Age of the driver(s) -Number of drivers -Type of vehicle
-Number of past claims -Commuting distance -Previous driving record
-Number of years driving -Number of years on an insurance policy

While all of these are considered in calculating the lowest premium for you, there are also a number of other factors that can reduce the cost of your premium:

-Mature discount -Retiree discount -Multi vehicle discount
-Multi driver discount -Low mileage rates -Renewal discounts
-Anti theft discounts -Defensive driving discounts
 
Have you considered all your options when buying auto insurance? As an independent agent representing several highly rated insurance companies, the professionals of Horizon Coast Insurance Services, LLC have the experience, expertise and resources to design an insurance program that fits you, your lifestyle and your automobile.

You need a financially strong insurance company offering quality products you can depend on. Horizon Coast Insurance Services, LLC can help you select the right insurance from the right company. We know that the true value of your insurance policy is in the responsiveness of the claim service at the time of your loss. That is why the companies we represent have been carefully selected to make sure they live up to your expectations. And, we are proud of the value we are able to offer you.

 

Please ensure you complete the quotation form as accurately as possible in order to ensure the best possible estimate. If you would rather speak to one of our representatives, Please Call (732) 521-3040 or e-mail: info@horizoncoast.com to setup a confidential consultation.

 
Completion of this form is for informational purposes only, and is just an estimate and is not a statement of contract. Coverage may not apply in all states. This WILL NOT result in a new policy, or change to an existing policy. For complete details of coverage, conditions, limits and losses not covered, be sure to read the policy, including all endorsements
<td > Accident Date / /
General Information
<td >Email address:
First Name:
Middle Initial:
Last Name:
 
Work Phone: Home Phone:
Best time to call:
AM PM
 
Street Address:
City:
State:
Zip Code:
County:
Present AUTO insurance company (not agent):
Expiration Date:
6-Month Auto Premium:
Present HOME insurance company (not agent):
Expiration Date:
12-Month Home Premium:
Number of years at current address:
If under 2 years, how long at previous address?
Do you own or rent your home?
Own Rent
Vehicles - List all vehicles titled or leased to you or your spouse.
Car #1
Year (4 digits)
Make (Buick, Honda, etc.)
Model (Century, Accord, etc.)
Sub-Model (2 dr Ltd, 4 dr LX, etc.)
Vehicle Identification #
Name of Title Holder
Annual Mileage Driven
How Car is Primarily Used
To and from work or school Business Calls
Deliveries Pleasure/Errands
  Miles one way:     Days per week:
Car #2
Year (4 digits)
Make (Buick, Honda, etc.)
Model (Century, Accord, etc.)
Sub-Model (2 dr Ltd, 4 dr LX, etc.)
Vehicle Identification #
Name of Title Holder
Annual Mileage Driven
How Car is Primarily Used
To and from work or school Business Calls
Deliveries Pleasure/Errands
  Miles one way:     Days per week:
Car #3
Year (4 digits)
Make (Buick, Honda, etc.)
Model (Century, Accord, etc.)
Sub-Model (2 dr Ltd, 4 dr LX, etc.)
Vehicle Identification #
Name of Title Holder
Annual Mileage Driven
How Car is Primarily Used
To and from work or school Business Calls
Deliveries Pleasure/Errands
  Miles one way:     Days per week:
Drivers - List all drivers in your household (SPOUSE MUST BE LISTED).
Driver Number #1 (self)
Last Name
First
Middle Initial
Birth date
/ /
At what age did you obtain your US license
Sex
M F
Marital Status
Occupation/Years
Car Driver Uses Most (#)
Driver Number #2
Last Name
First
Middle Initial
Birth date
/ /
At what age did you obtain your US license
Sex
M F
Marital Status
Occupation/Years
Car Driver Uses Most (#)
Driver Number #3
Last Name
First
Middle Initial
Birth date
/ /
At what age did you obtain your US license
Sex
M F
Marital Status
Occupation/Years
Car Driver Uses Most (#)
Driving History -List all violations, accidents, and losses.
Violations in past 5 years (3 yrs. in AZ, CA, DC, DE, FL, MD, MI, NC, NM, OK, OR, PA, SC, VA)
Driver Number
Violation Date
/ /
Description (speeding, stoplight, etc.)
Driver Number
Violation Date
/ /
Description (speeding, stoplight, etc.)
Driver Number
Violation Date
/ /
Description (speeding, stoplight, etc.)
Accidents in past 3 years
Dollar Amount and Description of Damage
Any Injuries?
Yes No
At Fault?
Yes No
Dollar Amount and Description of Damage
Any Injuries?
Yes No
At Fault?
Yes No
Dollar Amount and Description of Damage
Any Injuries?
Yes No
At Fault?
Yes No
Other Losses
List date, amount, and description of any losses such as theft, vandalism, glass breakage, hail loss, etc.
 
Discounts - Check those that apply. Not all discounts apply in every state.
Car #1
4-wheel anti-lock brakes Anti-theft device
Driver's-side air bag Automatic seat belts
Passenger's side air bags Vehicle garaged
Car #2
4-wheel anti-lock brakes Anti-theft device
Driver's-side air bag Automatic seat belts
Passenger's side air bags Vehicle garaged
Car #3
4-wheel anti-lock brakes Anti-theft device
Driver's-side air bag Automatic seat belts
Passenger's side air bags Vehicle garaged
3 years accident free Driver #1 Driver #2 Driver #3
6 years accident free Driver #1 Driver #2 Driver #3
Defensive Driver Course Driver #1 Driver #2 Driver #3
Coverage - Select options. (Please refer to your current insurance declarations page for accurate comparison.)
Liability limits - Same for all vehicles (check one)
$100,000 / $300,000 $50,000 / $100,000 Other    $
Property Damage Liability Limit (check one)
$50,000 $100,000 Other    $
Comprehensive Deductible (check one)
Car #1 $100 $250 $500 No Coverage Other    $
Car #2 $100 $250 $500 No Coverage Other    $
Car #3 $100 $250 $500 No Coverage Other    $
Collision Deductible (check one) - $100 deductible not available in NC, SC
Car #1 $100 $250 $500 No Coverage Other    $
Car #2 $100 $250 $500 No Coverage Other    $
Car #3 $100 $250 $500 No Coverage Other    $
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Please give any additional comments you feel appropriate for this quotation

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