Personal Auto Insurance Proposal Request (Georgia Residents ONLY)   For the fastest and most accurate automobile insurance quote, please provide as much information as possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!     Your Name Address City, State, Zip County (not country) Home Phone Work Phone Fax E-Mail Address     Vehicle Description Year Make & Model Body Style Vehicle ID # Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible Select 2-door coupe 2-door hatchback 4-door sedan Station Wagon Truck 2WD Truck 4WD Van Convertible       Vehicle Use & Discounts Vehicle Usage Miles One Way Driver Name Airbags Anti Lock Brakes Auto Seat Belts 1. Select Pleasure Drive to work Business Use Select None One Two Four Select None 2 wheels 4 wheels Select No Yes 2. Select Pleasure Drive to work Business Use Select None One Two Four Select None 2 wheels 4 wheels Select No Yes 3. Select Pleasure Drive to work Business Use Select None One Two Four Select None 2 wheels 4 wheels Select No Yes 4. Select Pleasure Drive to work Business Use Select None One Two Four Select None 2 wheels 4 wheels Select No Yes 5. Select Pleasure Drive to work Business Use Select None One Two Four Select None 2 wheels 4 wheels Select No Yes       Driver Information Name Sex Date of Birth Marital Status Occupation 1. Select Male Female Select Single Married Divorced 2. Select Male Female Select Single Married Divorced 3. Select Male Female Select Single Married Divorced 4. Select Male Female Select Single Married Divorced 5. Select Male Female Select Single Married Divorced     Additional Driver Information & Discounts Driver Driver Training Good Student Smoker Away at School Defensive Driver 1. Select No Yes Select No Yes Select No Yes Select No Yes Select No Yes 2. Select No Yes Select No Yes Select No Yes Select No Yes Select No Yes 3. Select No Yes Select No Yes Select No Yes Select No Yes Select No Yes 4. Select No Yes Select No Yes Select No Yes Select No Yes Select No Yes 5. Select No Yes Select No Yes Select No Yes Select No Yes Select No Yes       Please list all violations and accidents (including not-at fault accidents) for the last 5 years:   Liability / Uninsured Motorists / Medical Payments Liability Limit - Bodily Injury Select $250,000 /person, $500,000 /accident $100,000/ person, $300,000 /accident $50,000 /person, $100,000 /accident $25,000 /person, $50,000 /accident Liability Limit - Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident Uninsured/Underinsured Motorists Limit Select $250,000/person, $500,000/accident $100,000/person, $300,000/accident $50,000/person, $100,000/accident $25,000/person, $50,000/accident None Uninsured/Underinsured Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident None Medical Payments - Per Person Limit Select None $1,000 $2,000 $5,000 $10,000 $25,000 $50,000       Physical Damage Coverage & Deductibles Comprehesive Deductible Collision Deductible Towing Rental 1. Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Yes Select No Yes 2. Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Yes Select No Yes 3. Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Yes Select No Yes 4. Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Yes Select No Yes 5. Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Coverage $50 deductible $100 deductible $250 deductible $500 deductible $1,000 deductible Select No Yes Select No Yes Additional Information Do you currently have automobile insurance? Yes No Who is your current auto insurance company? When does your current policy expire? Current Premium every Select Year 6 Months 3 Months Month