Free E-Mail Quote
Available only to residents of Texas.

Personal Information

Name
Zip Code
(Optional) Phone Number
(Optional) Fax Number
E-mail
Do you have insurance now?	Yes    No   (Discount)
If yes,	Have you had insurance continuously for the last 6 months?   Yes   No
If no,	How long has your insurance been cancelled or expired? (Enter either number of days, date expired, or enter "NEW" if this is your first car.)
Do you own your own home?	Yes  No   (Discount)

Driver Information

	Age	Gender	Marital Status	Years Licensed	Tickets or Accidents in last 3 yrs	Driver required to file an SR-22 with state of Texas or other state?
Driver #1		M F	Married Single	1-2 yrs 2-3 yrs > 3 yrs">3 yrs">> 3 yrs	No Yes	No Yes
Driver #2		n/a M F	n/a Married Single	n/a 1-2 yrs 2-3 yrs > 3 yrs">3 yrs">> 3 yrs	n/a Yes No	n/a Yes No
Driver #3		n/a M F	n/a Married Single	n/a 1-2 yrs 2-3 yrs > 3 yrs">3 yrs">> 3 yrs	n/a Yes No	n/a Yes No
Driver #4		n/a M F	n/a Married Single	n/a 1-2 yrs 2-3 yrs > 3 yrs">3 yrs">> 3 yrs	n/a Yes No	n/a Yes No

For each ticket or accident, please list driver #, ticket or accident, and approximate date.

Motorcycle Information

	Year	Make	Model	VIN Number (If Possible)
Cycle #1
Cycle #2
Cycle #3
Cycle #4

Type of Coverage Desired

Descriptions of coverage are intended for general information only. Refer to your policy or consult an agent for details.

Liability -  (Bodily Injury and Property Damage Liability Insurance.)  Bodily Injury provides protection against damages  that you or a covered person are legally obligated to pay to a third party as a result of death or injury caused by the ownership, maintenance or use of a covered auto.  These damages may include medical expenses, lost wages and pain  and suffering.  Property Damage provides the same type of protection for damages such as to other vehicles, buildings  telephone poles and fences.  (These are just some of the examples of damages that can be covered.  For more information  it is always best to talk to an Insurance Agent.) Coverage quoted as : Bodily injury coverage per person/Bodily injury coverage per accident/Property damage coverage

$20,000/$40,000/$15,000 (Minimum Required by Texas) $25,000/$50,000/$25,000 $50,000/$100,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000  

Personal Injury Protection and Medical Payments - Personal Injury Protection (PIP) pays benefits because of bodily injury (1) because of a motor vehicle accident, and (2) sustained by a covered person. Other PIP benefits  consit of (1) reasonable expenses incurred for necessary medical and funeral services and (2) 80% of a covered persons loss of income from employment. These benefits apply, only if, at the time of the accident, the covered person was an  income producer, and was in an occupational status. Medical Payments is optional insurance that pays for reasonable  and necessary medical and funeral expenses for covered persons.  These expenses must be incurred as a result of an auto  accident. (These are just some of the examples of damages that can be covered.  For more information it is always best to talk to an Insurance Agent.)

Personal Injury None $1,000 $2,500 $5,000 $10,000      Medical Payments None $1,000 $2,500 $5,000 $10,000

Uninsured and Underinsured Motorist - Underinsured Motorist coverage pays for damages that you or a covered  person are legally entitled to recover from the owner or operator of a motor vehicle with sufficient bodily injury insurance.  These damages include medical expenses, lost wages and pain and suffering.  Uninsured Motorist coverage pays for damages that you or a covered person are legally entitled to recover from the owner or operator of a motor vehicle not covered by  bodily injury liability insurance.  These damages include medical expenses, lost wages and pain and suffering. (These are  just some of the examples of damages that can be covered.  For more information it is always best to talk to an Insurance Agent.)

Uninsured and Underinsured Motorist None $20,000/$40,000/$15,000 $25,000/$50,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000

Comprehensive and Collision Deductibles -  Comprehensive provides coverage for your auto for direct physical loss caused by other than collision, including theft, fire, wind, flood, vandalism and contact with an animal.   Collision covers your auto for physical loss caused by overturning or collision with another car or object, other than an animal. (These are just some of the examples of damages that can be  covered.  For more information it is always best to talk to an Insurance Agent.) (Most lienholders require Comprehensive and Collision with a maximum deductible of $500)

Comprehensive Deductible None $100 $200 $250 $500 $750 $1,000        Collision Deductible None $100 $200 $250 $500 $750 $1,000

Rental and Towing - Rental Reinbursement coverage is for reimbursement of expenses you incur to rent a substitute auto when (1) your covered auto is withdrawn from use for more than 24 hours, and (2) you have collision insurance on the covered auto. Towing coverage covers the cost of towing each time your covered auto is disabled.

Rental ($ per day) None $15 $20      Towing ($ per incident) None $20 $40 $50

Information is provided for the purposes of quoting only. Accuracy of the quote depends on information provided. Coverage is not bound by completion of this form. A credit check may be obtained to determine rates.