Daubenmire Insurance Agency, Inc. Auto Quote  1. Personal Information Name: E-mail: Address: Phone: City: Do you own your own home? Y N State: Present insurance co.: Zip: Current policy expires:  2. Passenger Car & Truck Information Veh. Year Make (Chevy/Ford) Model (Lumina/Taurus) Body (2 Dr./4 Dr.) 1 2 3 Veh. Cylinders Cost New Drive to Work/School? Estimated Annual Miles Miles 1 Way Days Per Wk. 1 $ 2 $ 3 $ Veh. Used in Business? Kept at Residence? Equipped w/ Anti-Lock Brakes? Equipped w/ Anti-Theft Device? Equipped w/ Automatic Seatbelts or Airbags? 1 Y N Y N Y N Y N Driver's Side Only Both Seat Positions 2 Y N Y N Y N Y N Driver's Side Only Both Seat Positions 3 Y N Y N Y N Y N Driver's Side Only Both Seat Positions  3. Driver Information Driver Date of Birth Sex Marital Status # Years Licensed % of Use Veh #1 Veh #2 Veh #3 1 M F 2 M F 3 M F TOTAL 100% 100% 100%  4. Accident History & Traffic Violations Has any driver had a license revoked? Yes No If yes, who, when, & why? Please explain: Any moving traffic violations or accidents in the past 5 years? Yes No If yes, list below: Driver Involved Date Amount of Damage Description of Accident or Traffic Violation (Speed/Stop Light/At Fault/Not at Fault) Anyone Injured? 123 Y N 123 Y N 123 Y N  5. Coverage Plans 1. Bodily Injury Liability: No Coverage $12,500/$25,000 $15,000/$30,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 5. Comprehensive Deductible: No Coverage $50 $100 $200 $250 $500 $1,000 2. Property Damage Liability: No Coverage $7,500 $15,000 $25,000 $50,000 $100,000 $250,000 6. Collision Deductible: No Coverage $50 $100 $200 $250 $500 $1,000 3. Uninsured / Underinsured Motorist: No Coverage $12,500/$25,000 $15,000/$30,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 7. Towing: Yes No 4. Medical Pay: No Coverage $1,000 $2,000 $5,000 $10,000 8. Rental: Yes No  Disclaimer To provide you with the lowest possible quote, we have asked you to give us some information that is needed to complete an auto quote. We will confirm this information through the use of consumer reports like Motor Vehicle, Financial Responsibility, and Loss Underwriting Reports. By clicking Submit below, you will be authorizing us to provide this information to the Insurance Carriers that we are licensed with to ensure you attain all possible discounts available. This information will be available to our Carrier's affiliated insurance companies operating within their corporate family to be certain you get a quote in the best possible plan.

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