ELITE - Truck Quote

- Use the additional info box to tell me anything else you think I should know

This quote is for: North Dakota

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:

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?

ANYTHING ELSE I NEED TO KNOW ABOUT YOUR CURRENT INSURANCE:

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:

BACK TO ELITE INSURANCE

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:

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?

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)

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