Auto Insurance Get a free auto insurance quote* emailed to you: Name   Email Address   City State   Zip Phone   Work Phone Automobile Information - Car 1 Year   Make [Ford, etc.] Model [Taurus, etc.] Body Type [2DR, 4DR, wagon, etc.]   Cylinders [4,5,6,8 or 12] Check if car used for business [other than to & from work] or farm: Business Farm Value of any special modified equipment [customized vehicles]  $ Days per week driven to work, school or parking One-way driving distance   Annual mileage Airbags:   None One Two Safety features [check all that apply]: Anti-lock brakes Automatic seat belts Active alarm Passive alarm Active disabling alarm Passive disabling alarm Please choose which limits you want quoted: Other than collision deductible no deductible50100   Collision deductible 100250500 Automobile Information - Car 2 Year   Make [Ford, etc.] Model [Taurus, etc.] Body Type [2DR, 4DR, wagon, etc.]   Cylinders [4,5,6,8 or 12] Check if car used for business [other than to & from work] or farm: Business Farm Value of any special modified equipment [customized vehicles]  $ Days per week driven to work, school or parking One-way driving distance   Annual mileage Airbags:   None One Two Safety features [check all that apply]: Anti-lock brakes Automatic seat belts Active alarm Passive alarm Active disabling alarm Passive disabling alarm Please choose which limits you want quoted: Other than collision deductible no deductible50100   Collision deductible 100250500 Automobile Information - Car 3 Year   Make [Ford, etc.] Model [Taurus, etc.] Body Type [2DR, 4DR, wagon, etc.]   Cylinders [4,5,6,8 or 12] Check if car used for business [other than to & from work] or farm: Business Farm Value of any special modified equipment [customized vehicles]  $ Days per week driven to work, school or parking One-way driving distance   Annual mileage Airbags:   None One Two Safety features [check all that apply]: Anti-lock brakes Automatic seat belts Active alarm Passive alarm Active disabling alarm Passive disabling alarm Please choose which limits you want quoted: Other than collision deductible no deductible50100   Collision deductible 100250500 If pickup truck or van, list cost new:   1. $ 2. $ 3. $ Are all vehicles kept at address provided?   Yes No If no, explain Driver 1 Information Driver name Has driver taken a state approved defensive/senior driving course?   Yes No Birth date   Sex:   Male Female Marital status:   Married Unmarried   Age first licensed Occupation [indicate if retired or student*]: How long in occupation? Percentage of use of car:   Car 1 Car 2 Car 3 Driver 2 Information Driver name Has driver taken a state approved defensive/senior driving course?   Yes No Birth date   Sex:   Male Female Marital status:   Married Unmarried   Age first licensed Occupation [indicate if retired or student*]: How long in occupation? Percentage of use of car:   Car 1 Car 2 Car 3 Driver 3 Information Driver name Has driver taken a state approved defensive/senior driving course?   Yes No Birth date   Sex:   Male Female Marital status:   Married Unmarried   Age first licensed Occupation [indicate if retired or student*]: How long in occupation? Percentage of use of car:   Car 1 Car 2 Car 3 *If student: Does student reside over 100 miles away from home?   Yes No Has student completed a state-approved driver training course?   Yes No Student's grade point average from last semester: Driving Records Within the last three years, has any driver had any accidents, traffic violations or other vehicle losses [for example, vandalism or towing]?   Yes No If yes, please describe [including dates, driver's name and cost of repairs, fines paid, type of violation and brief description]: Date   Driver's Name Cost/Fines paid   $ Description Date   Driver's Name Cost/Fines paid   $ Description Date   Driver's Name Cost/Fines paid   $ Description General Information Do you or any listed driver have a health or physical condition that may effect driving abilities?   Yes No If yes, please explain Have you or any listed driver ever been canceled or non-renewed by an insurance company?   Yes No Have you or any listed driver ever had driver's license suspended/revoked? Yes No How long have you lived at your present address? Your present policy expires Please choose which limits you want quoted: Bodily injury limit 25/5050/100100/300250/500   Property damage limit 2550100 Medical payments limit 500100020005000 Uninsured motorist bodily injury limit 25/5050/100100/300250/500 Uninsured motorist property damage limit 2550100 Uninsured motorist/underinsured motorist bodily injury limit 50/100100/300250/500 Uninsured motorist/underinsured motorist property damage limit 2550100 Towing & Labor 2550100   Rental reimbursement 153050 Back to top of page Tate's Insurance & Financial Services, Inc. Email: tates@tatesinsurance.com 945 N. Main Street · PO Box 548 Marion, NC 28752 Telephone [828] 652-7414 103 Mitchell Avenue · PO Box 48 Bakersville, NC 28705 Telephone [828] 688-9203 Fixed insurance office only Website design & maintenance by: DeZineShoppe.com *All estimated quotes are non-binding.

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