Thurston Insurance

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On-Line classic automobile Insurance Quote Form
Your Personal Data:
*Your Name
*Street Address
*City
*State
*Zip Code
*E-Mail
E-Mail (repeat)
*Phone
fax(optional)
 

Driver Information #1
*Name
*Birthdate
sex
*# Years US 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 (enter 0 if none)
*Number & Type of MINOR Accidents last 3 years (enter 0 if none)
*Number & Type of MAJOR Accidents last 3 years (enter 0 if none)
*Daily commute in ONE WAY miles
social security number (optional but needed for some companies to give price)
driver's license number (optional but needed for some companies to give price)
Does need an SR22 FILING
If yes to SR22, why needed?

Driver Information #2 (if none, leave blank)
Name
Birthdate
sex
# Years US 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 (enter 0 if none)
Number & Type of MINOR Accidents last 3 years (enter 0 if none)
Number & Type of MAJOR Accidents last 3 years (enter 0 if none)
Daily commute in ONE WAY miles
social security number (optional but needed for some companies to give price)
driver's license number (optional but needed for some companies to give price)
Does need an SR22 FILING
If yes to SR22, why needed?

If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here

Vehicle #1 Information
(if non-owner, type NON-OWNER in the YEAR field)
*Year of vehicle
*Make & Model
*Annual Mileage:
*Used in business?
(Explain if yes)
*Limit of Liability


*Comprehensive Coverage


*collision Coverage


Uninsured Motorists coverage
Rental car or towing coverage
Medical coverage

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)
Limit of Liability


Comprehensive Coverage


collision Coverage


Uninsured Motorists coverage
Rental car or towing coverage
Medical coverage
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here

Comments or remarks
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