Friendship Insurance
Stepping Out To Serve You
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about
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Quote Request
auto
business
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Contact Information
first name
last name
mobile
phone
email
address1
address2
city
state
zip
if you own your home,
how many years have you lived in it
Current Insurance Information
insurance company
Car Information
Car
1
make
model
year
title holder
vehicle ID# (VIN)
annual milage
if driven to school or work,
how many miles is it one way
if car kept at different address...
address1
city
state
zip
add another car
Liability Limit for
ALL
Cars
Choose BOTH
bodily injury
$0
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
property damage
$0
$25,000
$50,000
$100,000
Or ONLY single limit
$0
$100,000
$300,000
$500,000
$1,000,000
Other Coverages
personal injury protection
none
$2,500
$5,000
$10,000
medical payments
none
$2,500
$5,000
$10,000
uninsured/underinsured motorist
bodily injury
none
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
property damage
none
$25,000
$50,000
$100,000
Physical Damage Coverage
Car
1
comprehensive
none
$100 deductible
$250 deductible
$500 deductible
$1000 deductible
collision
none
$250 deductible
$500 deductible
$1000 deductible
towing
rental reimbursement
add coverage to next car
Driver Information
Driver
1
name
drivers license #
state
year issued
self
spouse
child
parent
other
birthdate
male
female
single
married
occupation
completed courses in last 3 years
drivers education
defensive driving
drug & alcohol awareness
add driver
Driving History
List ANY convictions for ANY driver convicted of moving
traffic violations
in last 3 years
Violation
1
driver name
date
conviction type
mph over limit
add violation
List ANY driver
involved in accidents
, regardless of fault, in last 5 years
Accident
1
driver name
date
description
cost
injuries?
yes — at fault?
yes
add accident
List ANY driver with license
suspensions, revocations, or DUI convictions
Suspension
1
offender name
suspension or revoked
result
suspension
revoked
DUI was for
alcohol, or
drugs
add suspension
notes
