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!


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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: 
Accident Prevention: 


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: 
Accident Prevention: 


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: 
Accident Prevention: 


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: 
Accident Prevention: 


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.

   


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