Jack Rice Insurance

PERSONAL AUTOMOBILE REQUEST

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. Please note that coverage cannot be bound or changed by using the Internet or Email.

Information
Name:
Address:
City:
State:
Zip:
Day Phone:	Eve. Phone:
Beeper:	Cell Phone:
E-mail Address:
Best Time To Contact:	AM PM
Method of contact:	Day Phone Eve. Phone Beeper Cell Email

Current Policy Information
Agent:
Insurance Company:
Policy Number:
Policy Expiration Date:

Driver Information:
	Driver 1	Driver 2	Driver 3	Driver 4
Name:
Relationship to Driver 1:
Occupation:
Length of Time at This Job:
Date of Birth:
Sex:	Male Female	Male Female	Male Female	Male Female
Marital Status:
Smoker?	Yes No	Yes No	Yes No	Yes No
If This Driver is 21 Years Old or Younger:
Has he/she Completed Driver's Education?	Yes No N/A	Yes No N/A	Yes No N/A	Yes No N/A
Is he/she a Student with a "B" Avg or Better?	Yes No N/A	Yes No N/A	Yes No N/A	Yes No N/A

Tickets and Accidents in the Past Five Years
Driver 1
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Driver 2
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Driver 3
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Driver 4
Incident 1:	Incident 2:
Incident 3:	Incident 4:

Number of Vehicles in your Household:

Vehicle Information

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Year:

Make:

Model:

Number of Doors:

Primary Driver?

Vehicle Identification Number:

Miles to Work (One Way):

Average Annual Mileage:

Airbags:

Automatic Seat Belts:

Yes No

Anti-Lock Brakes:

Yes No

Car Alarm

Coverage Information
	Comprehensive Deductible	Collision Deductible	Towing	Rental Reimbursement
Vehicle #1:				Yes No
Vehicle #2:				Yes No
Vehicle #3:				Yes No
Vehicle #4:				Yes No

Liability Limit for All Cars

Bodily Injury

Property Damage

UnInsured Motorist Limit for All Cars

Stacked?
Yes No

Information about your Driving Record

Has anyone in your household sustained any fire, theft or vandalism losses in the past 3 years?
Yes No

Have you or a household member had a foreclosure, repossession, bankruptcy, judgment or lien in the past 5 years? Yes No

Do all drivers live in the state 10 months out of the year? Yes No

Please explain any Yes answers here.