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Personal Information
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First
Name |
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Last
Name |
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Apt # |
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Address |
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City |
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Zip
Code |
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Home
Phone |
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Work
Phone |
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Ext. |
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E-mail |
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Fax |
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Cell |
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Auto Information
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Year of Auto |
Make of
Auto |
Model
Type |
# of
Doors |
# of
Cylinders |
Driver
% Used |
Annual
Miles Driven |
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Auto 1 |
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Auto 2 |
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Auto 3 |
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Auto 4 |
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Auto 5 |
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Driver Information
Accidents |
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Full Name |
Drivers License # |
Date of
Birth |
Sex |
Married |
Tickets |
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Non-Fault |
At - Fault |
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Driver 1 |
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Driver 2 |
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Driver 3 |
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Driver 4 |
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Driver 5 |
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Please List any tickets and accidents in the last 5 years |
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Desired Coverage Limits
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Bodily
Injury |
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Property Damage |
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Uninsured Motorist |
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Medical Coverage |
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Towing Coverage |
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Death Coverage
(Driver and Spouse) |
$15,000 coverage due
to death by an auto accident |
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Deductible's |
Collision |
Comprehensive
Rental Coverage |
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Auto 1 |
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Auto 2 |
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Auto 3 |
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Auto 4 |
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Auto 5 |
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Present Auto
Insurance Co. |
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Policy Expires (Month
/ Date) |
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Present Home
Insurance Co. |
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Policy Expires (Month
/ Date) |
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Can we offer you a Life Insurance Quote? |
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How were you referred |
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Comments / Request |
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Ask us about out Property /Auto
Discounts!
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By
clicking the Submit button I have Reviewed the
Privacy Statement
and the
Auto Insurance Disclosure Statement |
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and Understand that this
is only a quote for the State of California, any information and
does not constitute a binder |
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of coverage or proof
of Insurance in any form, or does it guarantee insurance. All
Coverage's are subject to the terms |
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and conditions contained
in the policy and endorsements. I agree the above information
is true and factual. Insurance |
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will not begin until I
sign the application and make a down payment. |
Please Read
Auto
Insurance Disclosure Statement below
This is not a binder or proof of Insurance
Insurance & Notary Services
Auto
Insurance Disclosure Statement Please Read Below
Thank you for the opportunity to discuss your Auto insurance needs.
I look
Forward to offering you the service and value that is
the standard of Ronn Hall Insurance. I am sure you will see
hat this quote can affordable enhance your insurance program.
Please Note:
An Insured which refuses to Provide coverage to an applicant who is
a “Good Driver” Must provide the applicant with a written
statement of the reasons it denied coverage. In general, under
California law a “good driver” is a person who, during the last
three years, Has been continually licensed and has not had more than
one violation point or more than One at-fault
accident resulting in only property damage.
As part of the
application process, Our Insurance Co. may collect personal information
from Persons other than you or other individuals proposed for
coverage, including credit reports, loss information reports
and motor vehicle reports. This information, as well as other personal
or privileged
information subsequently collected by us, may in certain circumstances be
disclosed to third parties without your authorization.
You have a right of access and correction with respect
to al personal information we collect. If you would like more detailed
information in writing about our information collection
practices, please let us know
All coverage’s are subject to the Terms and conditions
contained in the policy and endorsements.
The premiums shown are for a 6-month policy period.
If you have any questions please call me at the
Telephone number listed below.
Ask us about our Auto/ Home Discounts.
02/03/2011
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All material on this site is
intended for educational purposes only. Any proposals are not
contracts or binders, No coverage will be afforded until an application is
completed, signed, underwritten, and monies are exchanged. All Coverage's are subject to the terms and
conditions contained in the policy and endorsements. If you have any questions Please call us @ (619)
562-8585
The publishers are not responsible or liable for misinformation,
misprints, or typographical errors. All information provided is deemed reliable
but is not guaranteed and should be independently verified. We are not responsible
for advertisers listed on this site, please research your data prior to
making a purchase.
Some links are
"Paid Ads" and will transfer you to various web sites, others are
links
including Virginia Hall Coldwell Banker, Santee Real
Estate , Mortgage companies, insurance
companies, San Diego County
government sites,
including School Districts, and other web
sites.
All information provided is deemed reliable
but is not guaranteed and should be independently verified. We are not responsible
for advertisers listed on this site, please research your data prior to
making a purchase.
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