Davidson Insurance Agency

 

Print the quote information sheet.

Mail, fax, call or e-mail the information to our office.

You will be contacted within 48 hours of submission. *

*48 hours only applys if it occurs during our regular office hours. All requests will be contacted.

 

Collector / Elite Car Quote Information

 

 

Customer Information

 

Date:

 

Name

DOB

DL#

 

 

 

 

 

Address

SS#

Marital Status

 

 

 

oS    oM    oD    oW

 

 

 

Phone #

 

Vehicle Information

 

 

1

VIN#

Year

Make/Model

 

 

 

 

 

Usage:

Market Value

Annual Miles Driven

 

oWork  oSchool  oPleasure oOther

 

 

 

Vehicle is:

Under Restoration

Equipment Includes:

 

oStock   oModified

oYes   oNo

oWheelie bars

 

Owned by business or corporation?

If yes, % Restored?

oRoll bar/cage

 

oYes   oNo

          ________%

oNitrous oxide

 

Kept in locked garage or facility?

Garage State

o5-point seat restraints

 

oYes   oNo

 

 

 

 

 

 

2

VIN#

Year

Make/Model

 

 

 

 

 

Usage:

Market Value

Annual Miles Driven

 

oWork oSchool oPleasure  oOther

 

 

 

Vehicle is:

Under Restoration

Equipment Includes:

 

oStock   oModified

oYes   oNo

oWheelie bars

 

Owned by business or corporation?

If yes, % Restored?

oRoll bar/cage

 

oYes   oNo

          ________%

oNitrous oxide

 

Kept in locked garage or facility?

Garage State

o5-point seat restraints

 

oYes   oNo

 

 

 

 

 

Number of drivers in household

 

Total # of accidents in past 3 years:

 

o1  o2  o3  o4  o5  oMore

 

Total # of violations in past 3 years:

 

 

 

 

 

 

 

Coverages

 

 

 

Liability Limits

 

 

 

o50,000/100,000   o100,000/300,000

o250,000/500,000

oOther

 

Other than collision deductible

o$50         o$100  

o$250      o$500     o$1,000    

 

Collision deductible

o$50         o$100  

o$250      o$500     o$1,000    

 

 

 

 

 

Other coverages requested:

 

 

 

 

 

 

Photos will be required which include; two (2) exterior photos of each vehicle showing all four (4) sides. Additional photos may be required for modified vehicles; engine and interior.

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