QUOTE SHEET

Date: ___ / ___ / ___                                                        SD Address: _________________________________________________      

Phone: ( __ __ __ ) __ __ __ - __ __ __ __                  Email  Address: _______________________________________________

         ( __ __ __ ) __ __ __ - __ __ __ __

Customer Info: 

Name: _________________________  DOB: ___ / ___ / ___         Name:_________________________  DOB: ___ / ___ / ___

SSN#: __ __ __ - __ __ - __ __ __ __                                              SSN#: __ __ __ - __ __ - __ __ __ __ 

DL #: ____________________________ DL State: __ __               DL #: ____________________________ DL State: __ __

Speeding/Accidents: ____________________ Date: _______           Speeding/Accidents:_____________________ Date: _______

Safety Course: _____________________________                                                Safety Course: _____________________________

Current Ins. Carrier: _________________________

Vehicle Info:

RV:         MH  or 5^th  or TT

VIN # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Year: ________   Make: _________________    Model: ____________________    Length: ______  # Slides:_____

Misc. Detail Info: __________________________________________________________________

 Purchase Price: $__________                           List Price: $__________                                    Full Timer: Yes / No

Original Owner: Yes / No                                    Date Purchased: ___ / ___ / ___          

Current Liability Coverage: ________________    Comprehensive Deductible: $_______  Collision Deductible: $______ 

Roadside Assistance: Yes / No  Personal Effects $_________ 

AUTO #1

VIN # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Year: ________   Make: _________________    Model: ____________________ 

Current Liability Coverage: ________________    Comprehensive Deductible: $_______  Collision Deductible: $______

AUTO #2:

VIN # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Year: ________   Make: _________________    Model: ____________________

Current Liability Coverage: ________________    Comprehensive Deductible: $_______  Collision Deductible: $______

AUTO #3:

VIN # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Year: ________   Make: _________________    Model: ____________________

Current Liability Coverage: ________________    Comprehensive Deductible: $_______  Collision Deductible: $______