Copyright © 2002 CSE Insurance All Rights reserved. Author(s): Avinon Creation Date: Modified Date: 03/25/2002 Project : quoteCSE.com File : AutoQuote.cfm Purpose : This module collects information for a personal auto premium quotation. Modifications: Date Who Reason ---------- ------------ ----------------------------------------------- 04/05/2002 Bettina Gill collect driver info for up to four drivers, etc 03/11/2004 Bettina Gill add "how did you hear about CSE?" --> Request for Personal Auto Insurance Quote
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Auto Insurance Quote Form

For the fastest and most accurate Auto insurance quote, please provide as much information as possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY.
General Information
Name: *
Street address:
City: State: Zip: *
County: Email:
Day phone: * Evening phone:
Best time to call: * AM PM
Occupation:
Years at current job:         Are you a civil servant? Yes No
Prior insurance (yrs)? How long, in years, have you had continuous insurance?
Do you own a home? Yes No         Do you have good credit? Yes No
How did you hear about CSE?
Coverages Appropriate policy limits will be discussed over the phone.
Bodily Injury: ($000s, per person / per occurrence)
Property Damage: ($000s, per occurrence)
Medical Payments: ($000s)
Uninsured/Underinsured Motorist Coverage
 · Bodily Injury: ($000s, per person / per occurrence)
 · Property Damage: Yes No     (UM-PD or Collision Deductible Waiver depending on coverages chosen)
Vehicles 1 2 3 4
Year:
Make:
Model:
Annual mileage: miles/yr miles/yr miles/yr miles/yr
Used to commute? Yes No Yes No Yes No Yes No
Distance to work: miles one-way miles one-way miles one-way miles one-way
VIN
Special equipment: $ $ $ $
Discounts may be available for...
  daytime lights daytime lights daytime lights daytime lights
  anti-theft device anti-theft device anti-theft device anti-theft device
  driver-side airbag driver-side airbag driver-side airbag driver-side airbag
  passenger airbag passenger airbag passenger airbag passenger airbag
  side-impact airbag side-impact airbag side-impact airbag side-impact airbag
Coverages        
Rental: Yes No Yes No Yes No Yes No
Towing: Yes No Yes No Yes No Yes No
Deductibles        
Comprehensive:
Collision:
Drivers 1 2 3 4
Name:
Date of birth:
Age 1st licensed:
Sex: Male Female Male Female Male Female Male Female
Marital status: Single Married Single Married Single Married Single Married
Only drives occasionally? Yes No Yes No Yes No Yes No
Drives car... # # # #
Discounts may be available for...
  good student good student good student good student
  driver training driver training driver training driver training
  away at school away at school away at school away at school
  safe mature driver* safe mature driver* safe mature driver* safe mature driver*
  * Restrictions apply, e.g.: at least age 50 (differs by state), Mature Driver Improvement Course certificate, citation- and accident-free for three years.

Please indicate any major traffic convictions during the past seven years, and any minor citations and accidents during the past three years.
Major citations? Yes No Yes No Yes No Yes No
Minor citations? Yes No Yes No Yes No Yes No
Accidents? Yes No Yes No Yes No Yes No
Describe... If any citations or accidents, please provide brief description (driver name, date, description)


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