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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245
satisfaction
On-Line Automobile Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Street Address
City
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
Phone
Fax (optional)
Marital Status:
Single      Married
Homeowner?
Yes      No
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
DRIVER INFORMATION #1
Name
Birthdate
Sex (M/F)
# Years U.S. Licensing
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years
Number & Type of MINOR violations last 3 years
Number & Type of MAJOR violations last 3 years
Daily commute
in ONE WAY miles
Does Driver need an SR22 FILING?
Yes     No
If YES to SR22 filing, why needed?
(list accident/cite)
DRIVER INFORMATION #2 (if none, leave blank)
Name
Birthdate
Sex
# Years U.S. Licensing
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below
Number & Type of Accidents last 3 years
Number & Type of MINOR violations last 3 years
Number & Type of MAJOR violations last 3 years
Daily commute
in ONE WAY miles
Does Driver need an SR22 FILING?
Yes     No
Comments or
Remarks?
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here
VEHICLE #1 INFORMATION(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle
Make & Model
Vehicle ID# (for rating accuracy)
Annual Mileage
Used in business? (Explain, if yes)
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible
Uninsured Motorists Coverage?
YES      NO
Rental Car & Towing Coverage?
YES      NO
Medical and/or PIP Coverage?
YES      NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle
Make & Model
Vehicle ID# (for rating accuracy)
Annual Mileage
Used in business? (Explain, if yes)
VEHICLE #2 COVERAGES
Select Liability Limits
- - - Liability Limits Must
Match Vehicle #1 - - -
Select Comprehensive Deductible
Select Collision Deductible
Uninsured Motorists Coverage?
YES      NO
Rental Car & Towing Coverage?
YES      NO
Medical and/or PIP Coverage?
YES      NO
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:
Send my quotation via:
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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
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Simons Insurance Agency
CA License #0772640
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