Burnham & Flower
Home
Automobile Quote
General Information
Name
Current Insurance Company
Address
Current 6 month Premium (optional)
City
Zip Code
Phone (optional)
E-mail Address
Cell Phone
Social Security Number
How would you like us to contact you? e-mail Phone Cell Phone
.
Name of Drivers:
Sex:
Marital Status:
Date of Birth / Driver's License Number
Male
Female		 Married
Single
Male
Female		 Married
Single
Male
Female		 Married
Single
Driver History: For all drivers listed above, list all traffic violations, accident and automobile claims involving loss damage or injury in the past 3 years (include date, accident details, and cost.) Include all major violations regardless of the time period.

Vehicle Information
Year, Make & Model
Primary Use
Annual Mileage & VIN#
Business
Work
Pleasure
Business
Work
Pleasure
Business
Work
Pleasure
Vehicle 1 Vehicle 2 Vehicle 3
Type of Coverage:
Coverage Limits :
Liability Limit -
Bodily Injury & Property Damage
$50000
100000
300000
500000

Other $ 		$50000
100000
300000
500000

Other $ 		$50000
100000
300000
500000

Other $

Collision Deductible
$50
100
250		 $50
100
250		 $50
100
250

Comprehensive Deductible
$50
100
250		 $50
100
250		 $50
100
250

Towing
Yes
No		 Yes
No		 Yes
No

Rental Reimbursement
Yes
No		 Yes
No		 Yes
No

Do you have medical insurance? Yes No

We appreciate you taking the time to provide us with the requested information. We will contact you within 24 hrs. with your free, no-obligation automobile quote.
Wait! We value your opinion. Please list any comments you have regarding the completion of this form.