Khalsa Insurance Agency
 
California License # 0F89805
 
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Automobile Insurance Quote Form...
 
Full Name:
Address:
City:
State
ZIP:
Phone:
Work Phone Home Phone
   
E-Mail Address:
Current Auto Insurance Company:
Date Auto Insurance Expires:
Do you own a home?
Living at present Address since?
 
 
 
Car# Year VIN Make Model 2dr/4dr Miles to Work (one way) Annual
Mileage
               
1.
2.
3.
4.
5.
 
 
 
  Driver 1
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
Occupation:
# Tickets in Last 3 Years:
# Accidents in Last 3 Years:
   
% of Use
Car 1 Car 2 Car 3 Car 4 Car 5
 
  Driver 2
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
Occupation:
# Tickets in Last 3 Years:
# Accidents in Last 3 Years:
   
% of Use
Car 1 Car 2 Car 3 Car 4 Car 5
 
  Driver 3
   
Driver Name:
Date of Birth:
Sex:
Marital Status:
Occupation:
# Tickets in Last 3 Years:
# Accidents in Last 3 Years:
   
% of Use
Car 1 Car 2 Car 3 Car 4 Car 5
 
 
 
LIABILITY LIMIT FOR ALL CARS
Bodily Injury Property Damage Single Limit (choose one)
     
25,000 / 50,000 25,000 60,000
50,000 / 100,000 50,000 100,000
100,000 / 300,000 100,000 300,000
250,000 / 500,000 500,000 500,000
 
Choose either Bodily Injury & Property Damage OR Single Limit
 
 
 
Car # Deductible Comprehensive Deductible Collision Tow Loss of Use
         
1.
100 250 500
250 500 1000
Yes Yes
2.
100 250 500
250 500 1000
Yes Yes
3.
100 250 500
250 500 1000
Yes Yes
4.
100 250 500
250 500 1000
Yes Yes
5.
100 250 500
250 500 1000
Yes Yes
 
 
 
 
 
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    Legal Information   |   Khalsa Insurance Agency Inc. 2017