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Auto Insurance Quote

“ In order to get a prompt, accurate quote and to lock in the discounts you are entitled to, please answer the questions below. We keep all information you give us private and confidential. We will contact you within 24 hours!"

First Name	MI	Last Name
Street Address	Apt. #
City	State	Zip
Phone#	Best time to contact	Fax #
E-mail Address

Vehicle Description
Vehicle #1

Year	Make	Model
Number of Doors	Vehicle ID Number
How is this car used?

Vehicle #2

Year	Make	Model
Number of Doors	Vehicle ID Number
How is this car used?

Vehicle #3

Year	Make	Model
Number of Doors	Vehicle ID Number
How is this car used?

Vehicle #4

Year	Make	Model
Number of Doors	Vehicle ID Number
How is this car used?

Driver Information

Driver #1

Name	Marital Status
Date of Birth ,	Sex

Driver #2

Name	Marital Status
Date of Birth ,	Sex

Driver #3

Name	Marital Status
Date of Birth ,	Sex

Driver #4

Name	Marital Status
Date of Birth ,	Sex

Please list all traffic violations within 3 years and any accidents for
all driver listed (please include accidents deemed not-at-fault)

Current Coverage's

What company are you currently insured with?	What is the expiration date of your policy?
What is your current 6 month automobile premium?	Bodily injury Liability Limit
Uninsured Motorist Liability Limit	Personal Injury Protection
Comprehensive Deductible
Vehicle #1 #2 #3 #4
Towing Coverage Yes No	Rental Reimbursement CoverageYes No
Any other information you feel that is pertinent to your auto policy?

"Thank you for filling out this form for a quote.
We will contact you within 24 hours!"

Black & Associates Insurance Inc
8605 N. Division Spokane, WA
Citywide Call: 1-509-464-0058
Out of Area Call: 1-800-576-0075
info@jbbinsurance.com

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