CALIFORNIA LICENSE # 0F89805
 
 
   
 
AUTO INSURANCE
 
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
 
   
 
 
 
 
 
 
 
 
 
Visit LIQUORSTOREGASSTATIONINSURANCE.COM for insurance services for Liquor Stores, Gas Stations, Workers Compensation & Liquor Liability Insurance.
 
LIQUORSTOREGASSTATIONINSURANCE.COM is wholly owned by Khalsa Insurance Agency, Inc.
 
GET INSURED TODAY, CALL US AT: 408.272.2500
 
CALIFORNIA LICENSE # 0F89805
 
SAN JOSE OFFICE
 
Khalsa Insurance Agency, 3750, Mckee Road Suite, A, San Jose, CA, 95127, United States of America.
 
T # 408.272.2500     |     F # 408.493.4552     |     Email:  info@khalsainsurance.com     |     View Directions
 

 
FRESNO OFFICE
 
Khalsa Insurance Agency, 2125 N Barton Av., Fresno, CA 93703, United States of America.
 
T # 408.272.2500     |     F # 408.493.4552     |     Email:  info@khalsainsurance.com
 
 

 
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