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Request Ohio Auto Quote
Name
Address
City
Zip Code
Home Phone
Best Time to Call
Work Phone
Fax
E-Mail
Number of
Drivers
Vehicles
Current Insurer
Does your policy renew within 10 days?
No
Yes
Resident Status
Homeowner
Renter
DRIVER DATA (Oldest to Youngest)
First Name
Age
Sex
Martial Status
Record
(Number of) DUI
Accidents
Tickets
First Name
Age
Sex
Martial Status
Record
(Number of) DUI
Accidents
Tickets
First Name
Age
Sex
Martial Status
Record
(Number of) DUI
Accidents
Tickets
First Name
Age
Sex
Martial Status
Record
(Number of) DUI
Accidents
Tickets
LIMITS OF LIABILITY REQUESTED
Limits
Per Person / Per Occurrence / Property Damage
State Minimum
12.5 / 25 / 7.5
25 / 50 / 25
50 / 100 / 50
100 / 300 / 100
250 / 500 / 100
DEDUCTIBLES
Comprehensive
$0
$100
$250
$500
No Comprehensive Coverage
Collision
$100
$250
$500
$1000
No Collision Coverage
Towing Coverage Requested?
No
Yes
VEHICLE DATA
Year
Annual Miles Driven
Make/Model/Body
Number of Cylinders
4WD
No
Yes
Alarm
No
Yes
Airbag
No
Yes
ABS
No
Yes
Vehicle Use
Year
Annual Miles Driven
Make/Model/Body
Number of Cylinders
4WD
No
Yes
Alarm
No
Yes
Airbag
No
Yes
ABS
No
Yes
Vehicle Use
Year
Annual Miles Driven
Make/Model/Body
Number of Cylinders
4WD
No
Yes
Alarm
No
Yes
Airbag
No
Yes
ABS
No
Yes
Vehicle Use
Year
Annual Miles Driven
Make/Model/Body
Number of Cylinders
4WD
No
Yes
Alarm
No
Yes
Airbag
No
Yes
ABS
No
Yes
Vehicle Use
Have any of the above drivers had a suspended license in the past 5 years?
No
Yes
If Yes, Do you need an SR-22?
No
Yes
QUESTIONS COMMENTS
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213 South Sandusky Avenue | Upper Sandusky, OH 43351 | 419.294.4638 | fax 419.294.4694
131 Water Street | PO Box 452 | Prospect, OH 43342 | 740.494.9448 | fax 740.494.9879
Copyright © 2010 by Sunshine Insurance Agency
September 04, 2010
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