KDJ Insurance

Auto Insurance Quote Form

First Name	Last Name	E-mail Address *
Home #	Cell Phone #
		Zip Code
Location Address	City and State
		Best Time to Call
Drivers: (List all drivers in your household)
Name	Date of Birth
Name	Date of Birth
Name	Date of Birth
Name	Date of Birth
Vehicle #1	Vehicle #2	Vehicle #3
Year	Year	Year
Make	Make	Make
Model	Model	Model
VIN #	VIN #	VIN #
How is Car Primarily Used?	How is Car Primarily Used?	How is Car Primarily Used?
Work School Pleasure Only	Work School Pleasure Only	Work School Pleasure Only
Miles for Work/School	Miles for Work/School	Miles for Work/School

DESIRED COVERAGES
Liability Limits (in dollars):	Personal Injury Protection (PIP)	Uninsured/Underinsured Motorist Limits:
25,000/50,000/25,000 50,000/100,000,/50,000 100,000/300,000/100,000	$2,500 $5,000	$25,000/50,000 $50,000/100,000 $100,000/300,000
Comprehensive Deductible:
Vehicle #1	Vehicle #2	Vehicle #3
$100 $250 $500 $1,000 No Coverage	$100 $250 $500 $1,000 No Coverage	$100 $250 $500 $1,000 No Coverage
Collision Deductible:
Vehicle #1	Vehicle #2	Vehicle #3
$100 $250 $500 $1,000 No Coverage	$100 $250 $500 $1,000 No Coverage	$100 $250 $500 $1,000 No Coverage
Tow and Labor	Rental Reimbursement	Any tickets or accidents in the past 5 years?
Vehicle#1 Vehicle#2 Vehicle#3	Vehicle#1 Vehicle#2 Vehicle#3	Yes No
Name of Current Insurance Provider	Effective Dates of Policy	Medical Payments $500 $1000 $2500 $5000