Auto Quote Form

Full name?   **

Street address?   **

city, state, and zip code?
 **

Home phone number? 

Work phone number? 

Fax number? 

Type of residence? (example: condo, home, etc.) 

Own or rent?  own   rent  **

(if own) Would you like our agency to run your proposal with the multi-policy discount that might apply if Fusco Insurance insures your home and auto?  yes   no

Do you have a thorough understanding of your current auto policy coverages?  yes   no   I currently do not have an agent  **

Which company are you currently with?   **

When does your current policy expire? 

How long have you been insured with your current company?   **

PLEASE ENTER THE FOLLOWING INFORMATION FOR CAR 1.
Driver\'s name?   **

Sex?  male   female  **

Maritial Status?   **

Date Of Birth?   **

Social Security number? 

Years licensed?   **

Year/Make/Model of car?   **

How many miles on the car? 

(if applicable) When have you recieved tickets?   **

PLEASE ENTER THE FOLLOWING INFORMATION FOR CAR 2
Driver's Name? 

Sex?  male   female

Maritial Status? 

Date of birth? 

Social Security Number? 

Years licensed? 

The year, make, and model of the car? 

How many miles on the car? 

When have you recieved tickets? 

PLEASE ENTER THE FOLLOWING INFORMATION FOR CAR 3
Driver's Name? 

Sex?  male   female

Maritial Status? 

Date of birth? 

Driver's License number? 

Years licensed? 

The year, make, and model of the car? 

How many miles on the car? 

When have you recieved tickets? 

Social Security Number? 

Incidences & accidents in last 3 years (if applicable)? 

Current amount of bodily injury liability? 

How much bodily injury liability do you want?  25/50   50/100   100/300  **

How much property damage liability do you currrently have? 

How much property damage liability do you want?  10   25   50   100

How much Medical Payment coverage do you currently have? 

How much Medical Payment coverage do you want?  2,000   5,000   10,000   25,000

How much Uninsured Motorists coverage do you currently have? 

How much uninsured motorists coverage do you want?  25/50   50/100   100/300

How much collision deductible would you like on car 1?  250   500   1000

How much collision deductible do you want on car 2?  250   500   1000

How much collision deductible do you want on car 3?  250   500   1000

How much Comprehension Deductible do you want on car 1?  100   250   500   1000

How much Comprehension deductible do you want on car 2?  100   250   200   1000

How much Comprehension Deductible do you want on car 3?  100   250   500   1000

Emergency road service?  yes   no  **

Tapes/CDs Coverage?  yes   no  **

Sound Systems coverage?  yes   no  **

Camper Unit/Trailer coverage?  yes   no  **

Parts and Labor Plus?  yes   no  **

Motor Club Membership?  yes   no  **

What is your E-Mail Address? (Example: happygolucky@web.com)