Gozza Agency

The Gozza Agency, Inc. -- Automobile Insurance Quote Form

Automobile Insurance Quote
We would like to provide you with a free, no-obligation automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:
Primary Insured's Soc. Sec. #:

Current Auto Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Vehicle Information
(include all cars you or your family members own or lease)
Car #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Milage	Drive to school/work?	# of miles (one way)	Airbags	Car Alarm
			Y N		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)
Car #2
Name of Title Holder		Annual Milage	Drive to school/work?	# of miles (one way)	Airbags	Car Alarm
			Y N		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)
Car #3
Name of Title Holder		Annual Milage	Drive to school/work?	# of miles (one way)	Airbags	Car Alarm
			Y N		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #4	Year	Make	Model	Body Type	Vehicle ID# (VIN)
Car #4
Name of Title Holder		Annual Milage	Drive to school/work?	# of miles (one way)	Airbags	Car Alarm
			Y N		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Liability Limit For ALL Cars

Choose either Bodily Injury and Property Damage

or Single Limit

Bodily Injury

Property Damage

Single Limit

Deductibles and Misc.
Car#	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes
4			Yes	Yes

Driver Information
(include all licensed drivers in your household)
Driver #1	Driver's Name		Drivers License Information
			DL#: State: Yr's Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver #2	Driver's Name		Drivers License Information
			DL#: State: Yr's Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver #3	Driver's Name		Drivers License Information
			DL#: State: Yr's Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver #4	Driver's Name		Drivers License Information
			DL#: State: Yr's Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver History
List ANY convictions for ANY driver convicted of moving traffic violations* in the past 3 years*
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph
			$	mph
			$	mph

List ANY driver who has had license suspensions, revocations or DUI convictions* below*
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver	Date	Description	Cost	Fines	Injuries	At Fault
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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