(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

First Named Insured:

Second Named Insured:

 

*Full Name:

Full Name: 

*SSN #

*DOB:

SSN #

DOB:

           (ie;999-99-9999)

         (MM/DD/YYYY)

            (ie;999-99-9999)

       (MM/DD/YYYY)

*Contact Phone:   
Cell # 

Email: (EIA use only)

*Email: (EIA use only)

Current Carrier:

*Mailing Address:   
City: 
 State:    Zip:   Referred by:  

Policy #  
Expire Date:

Garaging Location:  City: State:

Driver Information:

         History Past 3 Years

Driver 1

Full Name


 

Driver's License #

State

DOB

Relationship to Primary Insured:

At fault accidents

Not At fault accidents

Violations/Tickets

Driver 2

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At fault accidents

Not At fault accidents

Violations/Tickets

Driver 3

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At fault accidents

Not At fault accidents

Violations/Tickets

Driver 4

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At fault accidents

Not At fault accidents

Violations/Tickets

 

Vehicle Information:

 

Year

Make

Model

VIN

Driver#

Use

Car 1

Car 2

Car 3

 

Car 4

 

Coverage Limits:

 

BI/PD

UMBI/PD

PIP/MED

COMP Ded

COLL Ded

Towing

 Rental Car

Car 1

Car 2

 same as car 1

same as car 1

same as car 1

Car 3

 same as car 1

same as car 1

same as car 1

Car 4

 same as car 1

same as car 1

same as car 1

Comments/Remarks:

 

Submission of quote request form to Raymond Longoria Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage.  To confirm binding or policy revision you must receive verbal or written confirmation from a RLI Group representative.