Lawrence and Wheeler, Inc.

Automobile

Quotation Request

Please provide the following information for a timely response via e-mail, telephone, fax or mail.


        Name: 
Mail Address: 
              
       Phone:   Fax: 
      e-mail: 
Contact me via:  Phone    FAX    e-mail

Location where vehicle is garaged: 
	
Do you or any drivers smoke?  Yes No
Vehicle Information

Year	Make ex: Ford	Model ex: Taurus	Engine	Doors	Air Bag?	ABS Brakes?	Miles to work	Bus. Use?
				2 4
				2 4
				2 4
				2 4


Driver Information

Driver's name	Birth Date	Sex	Marital Status
		M F	S M D
		M F	S M D
		M F	S M D
		M F	S M D


Accidents/Violations
  Has any driver had any accidents (regardless
  of fault) or had any violations within the 
  last 3 years?  Y  N
   
  If yes, please describe below (including cost of repairs 
  and any fines paid).  A Motor Vehicle Report may be ordered.
     Driver's name                Date        Description
  1.  
  2.  
  3.  

Coverage 
Liability/Uninsured Motorists: 
  Bodily Injury per Person per Accident
      50/100,000  100/300,000  250/500,000
  Property Damage per Accident
      50,000  100,000  300,000 500,000
  or Single Limit
      50,000  100,000  300,000  500,000
Medical Payments: (per person)
   1,000  5,000  10,000  Other
Other than collision (Deductible):
  Vehicle #1:  50  100  250  Other
  Vehicle #2:  50  100  250  Other
  Vehicle #3:  50  100  250  Other
  Vehicle #4:  50  100  250  Other
Collision (Deductible):
  Vehicle #1:  100  250  500  Other
  Vehicle #2:  100  250  500  Other
  Vehicle #3:  100  250  500  Other
  Vehicle #4:  100  250  500  Other
Towing and Labor: (per disabled vehicle)
  Vehicle #1:  25  50  75 
  Vehicle #2:  25  50  75 
  Vehicle #3:  25  50  75 
  Vehicle #4:  25  50  75 
Rental Reimbursement: (per Day/Maximum)
  Vehicle #1:  15/450  30/900  
  Vehicle #2:  15/450  30/900  
  Vehicle #3:  15/450  30/900  
  Vehicle #4:  15/450  30/900  


Miscellaneous Other Coverages (please list):
   
Comments: