I would like to request a quote for Auto Insurance     Personal Information Your Full Name Your Date of Birth Spouse Full Name Spouse Date of Birth Street Address Mailing Address City State Zip Code County Phone Number to Contact You E-Mail Address When Should we Contact You: Morning Lunch Afternoon Evening Do You Own Your Own Home or Rent: own Home Rent Home Other Is Your Home a Condominium or Townhouse Unit: Site Built Mobile Home Other Drivers in the Household and Their Ages: Are Any of the Drivers Full-Time Students With A 3.0 Average In Their Last Semester of School: Yes No Have You Had Any Violations or Accidents In The Last 3 Years: Yes No General Vehicle Information Current Insurance Carrier Renewal Date (If Known) Vehicle #1 List Name And Model of Vehicle Owned (i.e., 1997 Toyota Camry XLE) How They Are Used Approximate Annual Mileage Vehicle #2 List Name And Model of Vehicle Owned (i.e., 1997 Toyota Camry XLE) How They Are Used Approximate Annual Mileage Vehicle #3 List Name And Model of Vehicle Owned (i.e., 1997 Toyota Camry XLE) How They Are Used Approximate Annual Mileage Personal Injury Protection $2,500 $5,000 $10,000   Collision Deductible $250 $500 $1,000   Comprehensive Deductible $100 $200 $500   Bodily Injury $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000   Property Damage $25,000 $50,000 $100,000 $250,000   Policy Information Do you currently have an Umbrella policy: Yes No Do you currently have an Homeowners policy: Yes No Do you you own any life insurance policies outside of work: Yes No

The Avirett Agency, Inc. Full Service Insurance 123 North Main    Meridian, Texas  76665 Phone 254.435.2342  Fax 254.435.2003 This Page Last Updated 01/29/2007 ©2006, 2007 The Avirett Insurance Agency, Inc. All Rights Reserved