This quote is for:   North Dakota   Other State

Email address where your reply will be sent:	First Name	Last Name
	Street Address:	Apt or Suite:
	City:	State: Zip:
	Telephone 1:	Telephone 2:
DRIVER 1	DRIVER 2	DRIVER 3
Name:	Name:	Name:
Birthdate:	Birthdate:	Birthdate:
Driver License  State and Number:	Driver License State and Number:	Driver License State and Number:
SSN:	SSN:	SSN:

If you have never been licensed or your license is from a foreign country, tell me here:

Info about Insurance I have (or don't have):
(if your insurance expired recently, put the date in, because it may still be worth a discount)

I HAVE INSURANCE NOW I DON'T OR IT'S EXPIRED	WHEN DOES OR DID IT EXPIRE?	What Insurance Company do (or did) you have? (company - not agent)
		How long have you had the same company?
		What were your limits of liability? (e.g. 50/100 or 100/300)
		Did you have full coverage and if you did what were the deductibles?
		How much did it cost for 6 months?

ANYTHING ELSE I NEED TO KNOW ABOUT YOUR CURRENT INSURANCE:

TELL ME ABOUT YOUR LIVING ARRANGEMENTS:
(it may be possible to save money by putting you and your significant other on 1 policy)

I live all alone

Married living with spouse

I live with my significant other (might save money)

I have room-mates, but I don't want them on my insurance

I live with my parents

I live with a brother or sister or other relative (might save money)

DRIVING RECORD - best guess on the dates.... some companies go back 5 years, some go 3 years and some go 2 years

ACCIDENTS IN LAST 3 YEARS (best guess on the date and initials of what driver had it)	VIOLATIONS IN LAST 5 YEARS (WHO, what and when e.g. 1-15-02 DUI)	SPEEDING TICKETS IN LAST 5 YEARS (best gues on the date initials of what driver had it)

ANYTHING ELSE I SHOULD KNOW ABOUT YOUR RECORD:

VEHICLES

YEAR	MAKE	MODEL	VIN	I HAVE A LOAN OR I LEASE THIS VEHICLE	I WANT OR NEED FULL COVERAGE ON THIS VEHICLE

ANYTHING ELSE I SHOULD KNOW ABOUT YOUR VEHICELS: