South Florida Insurance Center

You can count on us. We've been serving the insurance needs of south Florida for over 25 years. We have the knowledge and we have the experience. Our customers count on our outstanding financial strength and superior claims service to help protect what they value.

[ Up ]

Back

Florida Auto Insurance

Quote Request Form

(For up to 2 cars and/or 2 drivers)

Unfortunately to prevent our constant need to contact you for additional information, our quote form is quite detailed in nature. Our goal is to provide you with the very best price that we can. This quote, however, must be based on the information that you provide. Please be as detailed as you feel necessary. There is an "additional information" area at the end. Feel free to use it. Hopefully, the space is adequate. If not, we have a "help us improve" department and we really would appreciate your suggestions!
Name	Mr. Mrs. Mr. and Mrs. Ms. First Name Middle Initial Last Name
Address	Street Address: Apt# City: State: Florida Zip Code:
Driver #1	Gender: Male Female Date of Birth: Month Day Year Marital Status: Single/Divorced Married Separated (If married, don't forget to list the info on your spouse as driver #2. To get a "preferred" rate with us (and most companies), both drivers and cars must be insured on one policy.) 5 Year Driving Record (All tickets and accidents, fault or not at fault) CLICK HERE for definitions of minor and major violations. No incidents within 5 years Date of Incident #1: (mo/yr) Type: Date of Incident #2: (mo/yr) Type: Date of Incident #3: (mo/yr) Type:
Driver #2	Gender: Male Female Date of Birth: Month Day Year Marital Status: Single/Divorced Married Separated Relationship to driver #1 5 Year Driving Record (All tickets and accidents, fault or not at fault) CLICK HERE for definitions of minor and major violations. No incidents within 5 years Date of Incident #1: (mo/yr) Type: Date of Incident #2: (mo/yr) Type: Date of Incident #3: (mo/yr) Type:
Current Insurance Company	Auto Insurance is currently in force? Yes No If no, date of cancellation (approximate is fine): *Name of Current Insurance Co.: Expiration Date: How long have you been with this company? Current Policy includes bodily injury liability? Yes No Insured with current or other carrier for prior 12 months continuously? Yes No Your prior insurance company and expiration date is critical in preparing an accurate quotation. If you have insurance, Please do not leave this area blank.** *We really don't care about who your current insurance company is unless it affects our underwriting guidelines. There are a very few companies that cater only to "bad" risks. Underwriting is different if you are currently with of one of these companies.
Car #1	Year:		Make:
	Model:	(include XLT, LS etc if applicable.)	Use:
	Check all that apply: AntiLock Brakes Burglar Alarm Lojack
Car #2	Year:		Make:
	Model:	(include XLT, LS etc if applicable.)	Use:
	Check all that apply: AntiLock Brakes Burglar Alarm Lojack
Limits Preferred: Liability Bodily Injury/Property Damage
Limit Preferred: Medical Payments
Limit Preferred: Uninsured Motorists
Collision Deductible	Car #1 Car #2
Comprehensive Deductible	Car #1 Car #2
Rental Reimbursement
Towing	Yes No
Discounts (Check all that apply) 55 and Retired Defensive Driving Course Good Student Claim& Accident free 3 years Claim& Accident free 5 years
Additional Information
How would you like your quotation sent?
E-mail
Fax