All Star Insurance Agency

DRIVER INFORMATION

Select Coverage & Options:

Auto

COMPLETE THE ENCLOSED FORM AND SUBMIT YOUR REQUEST. THANK YOU!

**OPTIONAL INFORMATION:

This information will give you an exact quote, without it the quote will be an estimate. This website has a security certificate from the web designer Heritage Web Solutions, Inc.

INDIVIDUAL AUTO INFORMATION

Name:
Address 1:
Address 2:
City:
State:	Nevada
Zip Code:
Daytime Phone:
Evening Phone:
Email:
Best Time to contact:

Driver No.	Name	Marital Status	Sex	Relation	**Birthdate	**Social Security Number	**Driver License Number	**State of Driver License Number	Vehicle Driven
1
2
3
4

VEHICLE INFORMATION

VEHICLE COVERAGE

Vehicle No.	Liability	UN/UIM	Medical	Compre- hensive	Collision	Towing	Rental
1
2
3
4

VEHICLE RATING

Vehicle	Use	Annual Miles	Airbags	Anti-Lock Brakes	Anti-Theft Device
1
2
3
4

DRIVING HISTORY - ACCIDENTS OR CLAIMS

Driver Number	Driving Tickets Last 3 Years	Accidents & Claims Last 3 Years
1
2
3
4

Current Auto Insurance? Yes No
Present Carrier:

Comments and Requests:

Home

COMPLETE THE ENCLOSED FORM AND SUBMIT YOUR REQUEST. THANK YOU!

**OPTIONAL INFORMATION:

This information will give you an exact quote, without it the quote will be an estimate. This website has a security certificate from the web designer Heritage Web Solutions, Inc.

INDIVIDUAL HOME INFORMATION

Name:
Address 1:
Address 2:
City:
State:	Nevada
Zip Code:
Daytime Phone:
Evening Phone:
Birthdate
**Social Security Number
Email:
Best Time to contact:

**Serial or VIN Number

Body Style

# of Cylinders

Property Address:
Name of your current insurance company:
Rent or Own:
Renewal Date:
Type of House:
Number of Stories
Square Footage of Home:
Year Built:
Garage Size:
Garage Type:
How Many Bathrooms:
Number of Fireplaces:
Type of Roof:
Dead Bolts, Fire Extinguisher & Smoke Alarm:
Construction Class:
Construction Type:
Security System Type:
Smoker:
Age 55 or Older:
Basement:
Located in Flood Zone:
Appraised Value of Home:
Dwelling Amount Coverage
Replacement Cost for Dwelling?
Replacement Cost for Contents?
Scheduled Property:	Amount & Type:
Liability:
Medical Payments to Others:
Deductible:
Number of Claims in the last 3 Years:

Description of Claims/Date/Type/Amount or Comments: