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E-Mail:
cforman@texas
wideinsurance.com

Phone Lines:
1-866-938-4708
1-979-822-4912

Facsimile:
1-877-203-0358

Mailing Address: 3620 E 29th St.
Bryan, TX 77802

Insurance
License #:

1100633

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On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: Must be Texas!
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


DRIVER INFORMATION #1
Name: Birthdate:
NOTE: Drivers License and Social Security fields are NOT mandatory, but if you supply them we can offer you the highest discounts and most accurate quote.
Driver's Lic#: Driver's Soc Sec.#:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No If YES to SR22 filing, why needed?
(list accident/cite)


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
NOTE: Drivers License and Social Security fields are NOT mandatory, but if you supply them we can offer you the highest discounts and most accurate quote.
Driver's Lic#: Driver's Soc Sec.#:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:
$30/60 BI / 25 PD (Basic Limits)
$50/100 BI / 50 PD $100/300 BI / 100 PD
$250/500 BI / 100 PD $500/500 BI/100 PD
 
Limits of
Uninsured Motorists:
$20/40BI /15PD   $25/50BI /25PD
$50/100BI /50PD $100/300BI /100PD
$250/500BI /100PD $500/500BI /100PD
 

Medical/PIP Coverage:
NO Coverage $2,500
$5,000 $10,000
 
Comprehensive
Coverage:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Rental Car &
Towing Coverage?
YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:
$30/60 BI / 25 PD (Basic Limits)
$50/100 BI / 50 PD $100/300 BI / 100 PD
$250/500 BI / 100 PD $500/500 BI/100PD
Limits of
Uninsured Motorists:
$20/40BI /15PD   $25/50BI /25PD
$50/100BI /50PD $100/300BI /100PD
$250/500BI /100PD $500/500BI /100PD
 

Medical/PIP Coverage:
NO Coverage $2,500
$5,000 $10,000
 
 
Comprehensive Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Rental Car &
Towing Coverage?
YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:


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