Anderson-VanHorne Associates, Inc.


AUTOMOBILE INSURANCE QUOTATION FORM To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name :
Last Name:
E-Mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:

DRIVER INFORMATION

	Name:	Relationship to applicant:	Sex:	Marital status:	Driver's age:	Which vehicle does he/she drive?	Percent use:
Driver #1			Male Female	Married Single
Driver #2			Male Female	Married Single
Driver #3			Male Female	Married Single
Driver #4			Male Female	Married Single

DRIVER HISTORY

Currently insured with (company name not agency):

Have you or any other driver in your household:

Had a ticket in the last 3 years?	Had a license suspended or revoked in the last 6 years?	Had a financial responsibility filing in the last 6 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No

If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City: State: Zip:

VEHICLE #2 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City: State: Zip:

VEHICLE #3 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City: State: Zip:

VEHICLE #4 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City: State: Zip:

COVERAGE OPTIONS

Bodily injury liability:
Property damage liability:
Underinsured motorist-bodily injury:
Underinsured motorist-property damage:
Medical-personal injury protection:
Accidental death:

COVERAGE DEDUCTIBLES

	Comprehensive deductible:	Collision deductible:	Towing coverage deductible:
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

Quotation Forms

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Securities and advisory services offered through Wall Street Financial Group, Inc., Registered Investment Advisor, Member FINRA/SIPC Wall Street Financial Group, Inc. may only transact business in those states and international jurisdictions where we are registered/filed notice or otherwise excluded or exempted from registration requirements. Any communications with prospective clients residing in international jurisdictions where Wall Street Financial Group, Inc., and its registered representatives are not registered or licensed shall be limited so as not to trigger registration or licensing requirements. Insurance services from D. Robert Anderson may not be provided to individuals residing in any states other than NY. Insurance services from Spencer Corzine may not be provided to individuals residing in any states other than NY and VA. Insurance products are not offered through Wall Street Financial Group, Inc. Securities services from D. Robert Anderson may not be provided to individuals residing in any states other than CA, FL, GA, MD, NY, NC, OK, and VA. Securities services from Spencer Corzine may not be provided to individuals residing in any states other than CA, FL, GA, MD, NY, NC, OK, PA, SC, and VA. Advisory services from D. Robert Anderson may not be provided to individuals residing in any states other than CA, MD, NY, NJ, and FL. Advisory services from Spencer Corzine may not be provided to individuals residing in any states other than CA, MD, NJ, NY and FL. Wall Street Financial Group did not assist in the preparation of this material, and its accuracy and completeness are not guaranteed. The opinions expressed are those of the author(s) and are not necessarily those of Wall Street Financial Group, Inc. The material has been prepared or is distributed solely for informational purposes and is not a solicitation or an offer to buy any security or instrument or to participate in any trading strategy. Wall Street Financial Group, Inc. is not responsible for information contained on websites listed herein. Wall Street Financial Group, Inc., Anderson-Van Horne Associates, Inc., and companies with websites listed herein are all separate entities, independently owned and operated.