 |
| For: |
Agent's Name |
| Lead ID: |
66746 |
| Insurance Type: |
Automobile |
| Date: |
07/28/2002 |
|
|
| Contact Information |
|
| Need Quote: |
ASAP |
Best Day: |
Anyday |
| |
|
Best Time: |
Anytime |
| Name: |
John Doe |
Day Phone: |
(850) 256-1276 x 23 |
| Address: |
4536 Alaska Ave |
Evening Phone: |
(850) 722-0310 |
| City: |
Kalskag |
Cell Phone: |
(878) 310-2386 |
| County: |
Bethel |
Fax: |
(850) 722-0310 |
| State: |
AK |
Email: |
johndoe@email.com |
| Zip Code: |
99607 |
Alternate Email: |
johndoe@altemail.com |
|
|
|
|
|
| Currently Insured: |
Yes |
Current Residence: |
Own |
| Current Carrier: |
Farmers |
Yrs at Current Residence: |
Less than 1 year |
| Renewal Date: |
6/3/2003 |
Yrs at Previous Residence: |
5+ years |
|
|
| Driver's Information |
| Name: |
John Doe |
Self |
Driver's License: |
AK |
| DOB: |
3/5/1961 |
Age: |
42 |
License Status: |
Active |
| Gender: |
Male |
Marital: |
Married |
Licensed (in US): |
15+ years |
| Prior Coverage: |
5+ years |
Drink: |
No |
Smoke: |
No |
| Filing Required: |
None |
Credit History: |
Average |
| Occupation: |
Employed |
Education: |
Associate Degree |
|
| Name: |
Joanna Doe |
Spouse |
Driver's License: |
AK |
| DOB: |
6/10/1963 |
Age: |
40 |
License Status: |
Active |
| Gender: |
Female |
Marital: |
Married |
Licensed (in US): |
15+ years |
| Prior Coverage: |
5+ years |
Drink: |
No |
Smoke: |
No |
| Filing Required: |
None |
Credit History: |
Average |
| Occupation: |
Employed |
Education: |
High School Diploma |
|
|
|
| Violation and Accident Information |
| John Doe |
| 07/2002 |
Failure to Stop |
| Comments: |
|
|
| Joanna Doe |
| 05/2003 |
Chargeable Accident - no Injury |
| Comments: |
Hit the car in the parking lot while backing |
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|
|
| Vehicle Information |
| Vehicle: |
2001 Toyota Corolla CE |
| VIN: |
453S2345DS2354 |
Primary Driver: |
John Doe |
| Ownership: |
Financed |
Security Device: |
Alarm, Disabling |
| Garage: |
Locked |
Homing Device: |
Teletrack |
| Usage: |
Commute |
One way: |
10 |
Air Bags: |
Dual, Head, Side |
| Annual Miles: |
12,000 |
ABS Brakes: |
2 wheels |
| Comp / Coll: |
500 / 500 |
Auto Belts: |
Yes |
| Salvaged: |
No |
Gap Coverage: |
Yes |
|
|
|
| Selected Coverage |
| BIPD: |
100/300/50 |
UMBI: |
15/30 |
UMPD: |
Yes |
| Towing: |
Yes |
Rental: |
Yes |
Medical: |
1,000 |
|
|
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| Comments: Please, contact me ASAP! |
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