Replacement Costs or Currently Insured for:
Home:  _________________________
Contents:  _________________________
Earthquake Coverage: Yes or No
Current Insurance Company:  _________________________
Any losses last 3 yrs? Yes or No
(If yes, what was loss)

Contacting You:
How should we contact you? Phone#, Fax# or E-Mail Address
Best time to reach you?  _________________________

Please complete the following form, and we will respond with a quotation for Automobile Insurance:

Name: _____________________
Date of Birth: _____________________
Yrs. Licensed in U.S.: _____________________
Spouse Name (if applicable): _____________________
Date of Birth: _____________________
Yrs. Licensed in U.S.: _____________________
Vehicle #1 Make/Year: _____________________
Model: please be specific, i.e.: Accord LX, Accord DX
Miles to work (one way): _____________________
Miles driven per year: _____________________
Vehicle #2 Make/Year: _____________________
Model: please be specific, i.e.: Accord LX, Accord DX
Miles to work (one way): _____________________
Miles driven per year: _____________________

Name of Company: _____________________
How Long with Company? _____________________

Towing: Yes or No
Rental Car Reimbursement: Yes or No

Traffic Violations
Be aware that providing incorrect information will result in invalid quotations.
List any accidents, tickets, DUI’s or suspensions within the last 5 years.

Town & Country Insurance
1126 Broadway Ste 5  Burlingame, Ca. 94010
Phone: 650-343-8450  Fax: 650-343-8456
Email:  info@town-countryinsurance.com