Parsons & Associates, Inc. -- Automobile Proposal Form

Parsons & Associates. Inc. -- Insurance & Risk Management

Auto

Automobile Insurance Proposal Form
For the fastest and most accurate automobile insurance proposal, please provide as much information possible in the form below. This information will be kept confidential and will be used for proposal purposes ONLY!

This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. Our goal is to respond to all submissions within two business days.

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We only accept inquiries for insurance written in New York State

General Information

Name:

Address:

City: State: Zip:

Day Phone: Night Phone:

Best Time To Call: AM PM

Email Address:

Current Auto Insurance Information

Company Name (not agency):

Policy Expiration Date: Premium Amount: $

Term: 6 Months 1 Year Other:

Vehicle Information

(include all cars you or your family members own or lease)

Car
#1 Year Make Model Body Type Vehicle ID# (VIN)

Name of Title Holder Annual Milage Drive to school/work? # of miles Airbags Car Alarm

Y N one way Y N Y N

If vehicle is kept at an address other than that listed above, please indicate below

Location City: State: Zip:

Car
#2 Year Make Model Body Type Vehicle ID# (VIN)

Name of Title Holder Annual Milage Drive to school/work? # of miles Airbags Car Alarm

Y N one way Y N Y N

If vehicle is kept at an address other than that listed above, please indicate below

Location City: State: Zip:

Car
#3 Year Make Model Body Type Vehicle ID# (VIN)

Name of Title Holder Annual Milage Drive to school/work? # of miles Airbags Car Alarm

Y N one way Y N Y N

If vehicle is kept at an address other than that listed above, please indicate below

Location City: State: Zip:

Car
#4 Year Make Model Body Type Vehicle ID# (VIN)

Name of Title Holder Annual Milage Drive to school/work? # of miles Airbags Car Alarm

Y N one way Y N Y N

If vehicle is kept at an address other than that listed above, please indicate below

Location City: State: Zip:

Liability Limit For ALL Cars

Choose either Bodily Injury and Property Damage
Bodily Injury Property Damage
or Single Limit
Single Limit

Deductibles and Misc.

Car# Comprehensive Deductible Collision Deductible Towing Loss of Use

1 Yes Yes

2 Yes Yes

3 Yes Yes

4 Yes Yes

Please Note: In order to provide you the most accurate policy quote, some of the companies we represent may require a credit and/or claims history which require your Social Security Number. You do not have to provide social security numbers at this time, however we cannot guarantee that we can provide you the most accurate quotation until we secure your credit information. We will not share this infomation with any other entity other that prospective insurance companies that will assist us in preparing your quote. All information on this form will be strictly used for internal purposes only

Driver Information

(include all licensed drivers in your household)

Driver
#1 Driver's Name Drivers License Information

DL#: State: Years Licensed:

Relation Date of Birth Sex Marital Status Soc. Sec. # Courses Completed Last 3 yrs

M
F Married
Single Drivers Ed: Y N
Accident Prevention: Y N

Driver
#2 Driver's Name Drivers License Information

DL#: State: Years Licensed:

Relation Date of Birth Sex Marital Status Soc. Sec. # Courses Completed Last 3 yrs

M
F Married
Single Drivers Ed: Y N
Accident Prevention: Y N

Driver
#3 Driver's Name Drivers License Information

DL#: State: Years Licensed:

Relation Date of Birth Sex Marital Status Soc. Sec. # Courses Completed Last 3 yrs

M
F Married
Single Drivers Ed: Y N
Accident Prevention: Y N

Driver
#4 Driver's Name Drivers License Information

DL#: State: Years Licensed:

Relation Date of Birth Sex Marital Status Soc. Sec. # Courses Completed Last 3 yrs

M
F Married
Single Drivers Ed: Y N
Accident Prevention: Y N

Driver History

Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years

Driver Date Type of Conviction Fines Speed Over Limit

$ mph

$ mph

$ mph

$ mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions below

Driver License Suspended or Revoked DUI Conviction For:

Suspended Revoked Alcohol Drugs

Suspended Revoked Alcohol Drugs

Suspended Revoked Alcohol Drugs

Suspended Revoked Alcohol Drugs

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years

Driver Date Description Cost Fines Injuries At Fault

$ $ Yes Yes

$ $ Yes Yes

$ $ Yes Yes

$ $ Yes Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Proposal" button to send your proposal request.
One of our representatives will respond to your submission as soon as possible.

General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Auto Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Vehicle Information
(include all cars you or your family members own or lease)
Car #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #4	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Liability Limit For ALL Cars
Choose either Bodily Injury and Property Damage Bodily Injury Property Damage	or Single Limit Single Limit

Deductibles and Misc.
Car#	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes
4			Yes	Yes

Driver Information
(include all licensed drivers in your household)
Driver #1	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M F	Married Single		Drivers Ed: Y N Accident Prevention: Y N

Driver #2	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M F	Married Single		Drivers Ed: Y N Accident Prevention: Y N

Driver #3	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M F	Married Single		Drivers Ed: Y N Accident Prevention: Y N

Driver #4	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M F	Married Single		Drivers Ed: Y N Accident Prevention: Y N

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations* in the past 3 years*
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph
			$	mph
			$	mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions* below*
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.