Fax Auto Insurance

1. What is your email?
2. What is your name?
3. What is your zip code?
4. Are you single, married, divorced or widowed?
5-7. Primary car year, make & model
8. Primary car - full coverage or liability?
9-11. Second car year, make & model
12. Second car - full coverage or liability?
13-15. Third car year, make & model
16. Third car - full coverage or liability?
17-19. Fourth car year, make & model
20. Fourth car - full coverage or liability?
21. What is your address?
22. What is your city?
23. Do you have a house, mobile home, apartment or other?
24. Do you rent or own?
25. Who is your current insurance company?
26. How long have you had this coverage without a lapse?
27. Do you know your current liability limits? (20/14/15) (25/50/25) or enter another
28. Driver 1 Name
29. Driver 1 DOB
30. Driver 1 TDL
31. Driver 1 SS#
32. Driver 2 Name
33. Driver 2 DOB
34. Driver 2 TDL
35. Driver 2 SS#
36. Driver 3 Name
37. Driver 3 DOB
38. Driver 3 TDL
39. Driver 3 SS#
40. Who's name are the vehicles title in?
41. Do you have an auto loan or mortgage through GMAC?
42. Have you or any of these drivers had tickets - whether at fault or not in the past three years?
43. Have you or any of these drivers had accidents - whether at fault or not in the past three years?
44. Have you or any of these drivers had claims - whether at fault or not in the past three years?
45. Do you have any other licensed drivers that live in your home? (Yes or No)
46. Other Driver 1 Name
47. Other Driver 1 Relationship
48. Other Driver 1 DOB
49. Other Driver 2 Name
50. Other Driver 2 Relationship
51. Other Driver 2 DOB
52. What is your phone number?
53. What is an alternate phone number?
54. What is your fax number?
55. How did you hear about us? From the phone book, a friend, the Internet, or other

Roy Elliott 308 South Main, Highlands, Texas 77562 Phone 281-843-2947 Fax 28
1-426-3836 Email: MetRoyElliott@aol.com