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 applies if it occurs during our regular office hours. All requests will be contacted.

Phone: 218-485-8735

Fax: 218-485-4169

E-mail: yvonne@davidson-agency.com

 

 

Driver Information

 

 

Date _____/______/______

 

 

 

 

Phone # 

 

Name

DOB

DL#

Marital Status 

1

 

 

 

 

2

 

 

 

 

3

 

 

 

 

4

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

Vehicle Information – VIN #

Year

Make

Model

1

 

 

 

 

2

 

 

 

 

3

 

 

 

 

4

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

Assignment of Drivers - Name

Usage

Distance

Loan Info.

1

 

 

 

 

2

 

 

 

 

3

 

 

 

 

4

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

Currently Insured?

Current Company

Limits of Liability

Current Premium

 

oYes    oNo  If no, date of last policy

 

o 50,000/100,000

 

 

Other Than Collision

 

o 100,000/300,000

 

 

Additional Options

 

Deductible Amount

o$100

o$250

o 250,000/500,000

o$500

o$1,000

o Other

 

Collision

 

 

 

Deductible Amount

o$100

o$250

o$500

o$1,000

 

GAP Coverage

 

 

PIP – o Stacked        o  Non-Stacked

 

 

Rental Reimbursement

 

 

Towing & Labor    per occurrence

o$25    o$50    o$75   o $100

 

 

 

CLAIMS & ACCIDENTS within  5 years

 

 

 

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