All Star Insurance Agency

DRIVER INFORMATION

Select Coverage & Options:

INDIVIDUAL/FAMILY INFORMATION

BUSINESS INFORMATION

INDIVIDUAL LIFE INFORMATION

Select Coverage & Options:

Auto

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**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

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**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:

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:

Business

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BUSINESS INFORMATION

Business:
Owners Name:
Address 1:
Address 2:
City:
State:	Nevada
Zip Code:
Daytime Phone:
Evening Phone:
Email:
Entity Type:
Years in Business:
Years Experience in Business:
Business Description:
Gross Annual Sales:
Gross Annual Payroll:
Dwelling Amount:
Business Personal Property:
Deductible:
Liability Amount:
Medical Payments:
Vehicle Coverage:	Refer to Auto Quotes.

Vehicle Coverage Summary and Additional Comments

Health

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INDIVIDUAL HEALTH INFORMATION

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

Name of your Current Insurance Company:

Healthcare:
Deductible:
Co-Insurance:
Office Visit Co-Pay:
Maternity:	Yes No
Tobacco Use:

First Name	Last Name	Birthdate	Sex	Height	Weight

Number of Children:

List all pre-existing medical conditions:

List all medications taken for each person - Daily Dosage - Inception date on taking medication:

GROUP HEALTH INSURANCE

Company Name:
Number of Employees:
Contact Person:
Business Phone:
City
State	Nevada

Name of your Current Insurance Company:

Healthcare:
Deductible:
Co-Insurance:
Office Visit Co-Pay:

Life

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

**Serial or VIN Number

Body Style

# of Cylinders

Term Insurance:
Age:
Sex:
Tobacco Use:
Insurance Amount:
Health Status:

List all pre-existing medical conditions:

List all medications taken for each person - Daily Dosage - Inception date on taking medication: