The Ted Hartleb Agency

Without the Love, it's just Insurance

AUTO INSURANCE QUOTE

Name *

Address *

Phone Number *

Date of Birth *

SOCIAL SECURITY NUMBER

DRIVERS LICENSE NUMBER

DO YOU HAVE ANY TICKETS OR AT FAULT ACCIDENTS IN THE LAST 5 YEARS?
Yes
No

HAVE YOU MADE ANY CLAIMS ON YOU INSURANCE IN THE LAST 5 YEARS?
Yes
No

DO YOU HAVE INSURANCE NOW?
Yes
No

WHO IS IT THROUGH?

WHEN IS YOUR EXPIRATION DATE?

DO YOU KNOW WHAT YOU ARE CURRENTLY PAYING?

WHAT KIND OF CAR DO YOU DRIVE?

DO YOU HAVE THE VEHICLE NUMBER (VIN)

2 OR 4 DOOR?
2
4

2 OR 4 WHEEL DRIVE?
2
4

ANY TYPE OF ALARM SYSTEM?

DO YOU DRIVE THE VEHICLE TO WORK?
Yes
No

HOW MANY MILES ONE WAY?

WOULD YOU LIKE FULL COVERAGE OR PLPD?
FULL COVERAGE
PLPD

WHAT DEDUCTIBLES WOULD YOU LIKE FOR COMP. AND COLLISION?

DO HAVE MEDICAL INSURANCE?
Yes
No

DOES IT COVER VEHICLE ACCIDENTS?
Yes
No

DO YOU HAVE A LOAN/LEASE ON THE VEHICLE?
Yes
No

Do you want towing & labor and rental reimbursement?
Yes
No

HIGHEST LEVEL OF EDUCATION?

WHO DO YOU WORK FOR?

ANY OTHER VEHICLES?

ANY OTHER DRIVERS?
Yes
No

NAME

DOB

SOCIAL SECURITY NUMBER

DRIVERS LICENSE NUMBER

WHICH VEHICLES DO THEY DRIVE?

HOW DID YOU HEAR ABOUT US?

THIS IS NOT AN APPLICATION OR A CONTRACT, IT IS FOR INFORMATION PURPOSES ONLY.