The Ted Hartleb Agency
Without the Love, it's just Insurance
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AUTO INSURANCE QUOTE
Name
*
Address
*
Phone Number
*
Date of Birth
*
SOCIAL SECURITY NUMBER
DRIVERS LICENSE NUMBER
DO YOU HAVE ANY TICKETS OR AT FAULT ACCIDENTS IN THE LAST 5 YEARS?
Yes
No
HAVE YOU MADE ANY CLAIMS ON YOU INSURANCE IN THE LAST 5 YEARS?
Yes
No
DO YOU HAVE INSURANCE NOW?
Yes
No
WHO IS IT THROUGH?
WHEN IS YOUR EXPIRATION DATE?
DO YOU KNOW WHAT YOU ARE CURRENTLY PAYING?
WHAT KIND OF CAR DO YOU DRIVE?
DO YOU HAVE THE VEHICLE NUMBER (VIN)
2 OR 4 DOOR?
2
4
2 OR 4 WHEEL DRIVE?
2
4
ANY TYPE OF ALARM SYSTEM?
DO YOU DRIVE THE VEHICLE TO WORK?
Yes
No
HOW MANY MILES ONE WAY?
WOULD YOU LIKE FULL COVERAGE OR PLPD?
FULL COVERAGE
PLPD
WHAT DEDUCTIBLES WOULD YOU LIKE FOR COMP. AND COLLISION?
DO HAVE MEDICAL INSURANCE?
Yes
No
DOES IT COVER VEHICLE ACCIDENTS?
Yes
No
DO YOU HAVE A LOAN/LEASE ON THE VEHICLE?
Yes
No
Do you want towing & labor and rental reimbursement?
Yes
No
HIGHEST LEVEL OF EDUCATION?
WHO DO YOU WORK FOR?
ANY OTHER VEHICLES?
ANY OTHER DRIVERS?
Yes
No
NAME
DOB
SOCIAL SECURITY NUMBER
DRIVERS LICENSE NUMBER
WHICH VEHICLES DO THEY DRIVE?
HOW DID YOU HEAR ABOUT US?
THIS IS NOT AN APPLICATION OR A CONTRACT, IT IS FOR INFORMATION PURPOSES ONLY.