Please provide the following contact information:

First Name:
Last Name:
Street Address:
City:
County:
State:	NC SC         Zip Code:
E-mail address:
Home Phone:	- -
Work Phone:	- -
How should we contact you?	Email Mail Phone (Work) Phone (Home)

 

Driver Information: (All drivers in your household must be listed on your quote.) Driver One Name: Drivers Licence #: Gender: Male Female Date of Birth: Marital Status: Married Single Divorced Widow Years Licensed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 over 15   Driver 2 Name: Drivers Licence #: Gender: Male Female Date of Birth: Marital Status: Married Single Divorced Widow Years Licensed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 over 15   Driver Three   Name: Drivers Licence #: Gender: Male Female Date of Birth: Marital Status: Married Single Divorced Widow Years Licensed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 over 15   Driver Four   Name: Drivers Licence #: Gender: Male Female Date of Birth: Marital Status: Married Single Divorced Widow Years Licensed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 over 15     Accident/Violation/Claim History (past 36 months) Incident 1 Date: Driver: 1 2 3 4 Description: No Accidents/Violations/Claims DUI/DWI License Suspension/Revocation Failed to obey traffic signal Speeding 1-10 mph over limit Speeding 11-15 mph over limit Speeding 16 mph or more over Careless/Reckless Driving Other Minor Violation Other Major Violation Financial Responsibility/SR22 filing Hit another vehicle Another vehicle hit me Hit a fixed object (tree,etc.) Struck an animal Damage due to fire, theft or vandalism Windshield or glass damage Incident 2 Date: Driver: 1 2 3 4 Description: No Accidents/Violations/Claims DUI/DWI License Suspension/Revocation Failed to obey traffic signal Speeding 1-10 mph over limit Speeding 11-15 mph over limit Speeding 16 mph or more over Careless/Reckless Driving Other Minor Violation Other Major Violation Financial Responsibility/SR22 filing Hit another vehicle Another vehicle hit me Hit a fixed object (tree,etc.) Struck an animal Damage due to fire, theft or vandalism Windshield or glass damage Incident 3 Date: Driver: 1 2 3 4 Description: No Accidents/Violations/Claims DUI/DWI License Suspension/Revocation Failed to obey traffic signal Speeding 1-10 mph over limit Speeding 11-15 mph over limit Speeding 16 mph or more over Careless/Reckless Driving Other Minor Violation Other Major Violation Financial Responsibility/SR22 filing Hit another vehicle Another vehicle hit me Hit a fixed object (tree,etc.) Struck an animal Damage due to fire, theft or vandalism Windshield or glass damage Incident 4 Date: Driver: 1 2 3 4 Description: No Accidents/Violations/Claims DUI/DWI License Suspension/Revocation Failed to obey traffic signal Speeding 1-10 mph over limit Speeding 11-15 mph over limit Speeding 16 mph or more over Careless/Reckless Driving Other Minor Violation Other Major Violation Financial Responsibility/SR22 filing Hit another vehicle Another vehicle hit me Hit a fixed object (tree,etc.) Struck an animal Damage due to fire, theft or vandalism Windshield or glass damage     Vehicle Information Vehicle 1 Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage: Commuting Pleasure Business   Vehicle 2 Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage: Commuting Pleasure Business   Vehicle 3 Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage: Commuting Pleasure Business   Vehicle 4 Year: Make: Model/Model Number: VIN (Vehicle Identification Number): Body Type: Usage: Commuting Pleasure Business   Coverage Information Bodily Injury (Per Person/Per Accident): $30,000/60,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 Property Damage: $25,000 per accident $50,000 per accident $100,000 per accident Medical Coverage: $500 1,000 2,000 5,000 No Coverage Towing and Labor: $25 $50 $100 No Coverage Extended Transportation: $15 per day/$450 max $30 per day/$900 max No Coverage Comprehensive Coverage: Vehicle 1: Full - no deductible $50 deductible $100 deductible $250 deductible $500 deductible $1000 deductible No coverage Vehicle 2: Full - no deductible $50 deductible $100 deductible $250 deductible $500 deductible $1000 deductible No Coverage Vehicle 3: Full - no deductible $50 deductible $100 deductible No Coverage $500 deductible $1000 deductible No coverage Vehicle 4: Full - no deductible $50 deductible $100 deductible $250 deductible $500 deductible $1000 deductible No Coverage Collision Coverage: Vehicle 1: $250 deductible $500 deductible $1000 deductible No Coverage Vehicle 2: $250 deductible $500 deductible $1000 deductible No Coverage Vehicle 3: $250 deductible $500 deductible $1000 deductible No Coverage Vehicle 4: $250 deductible $500 deductible $1000 deductible No Coverage Other Coverages:   General Information Your occupation: Your Employer: Total number of years employed: years Current Insurance company: How long have you been continuously insured? Under 6 months 6 months to 1 year Over 1 year How did you hear about Barnette and Coates Insurance? Newspaper Radio Yellow Pages Web Referral Policy Expiration Date: Do you own your home? Yes No How long have you lived at your current residence? years Additional Comments: