Kinghorn Insurance of Beaufort
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Auto Insurance Quote Information
Basic Info
Who Referred You?
Referred by
Donna Collum
Ed Hamilton
Felicia Medina
Jamey Smith
Jason Fleer
Marcus Henneke
Nancy Zayats
Nathan Dagley
Robbie Cox
Ryan Moore
Ryan Wilson
William Presley
Other
Preferred Contact Method
E-Mail
Phone
Doesn't Matter
Preferred Contact Time
Morning
Afternoon
Evening
Whenever
*First Name
*Last Name
Address
City
State
ZIP
Code
*Primary Phone
*E-Mail
Current Ins. Carrier
Current Insurance Premium
Any Coverage Lapse? (over 30 days)
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Vehicle Information
Year
Make
Model
Air Bag?
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Vehicle Identification Numbers
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Driver Info – All Licensed Drivers in Household
Name
D/O/B*
D.L. #
Married?
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
In the last 3 years have you had any Accidents/Claims?
In the last 5 years have you had any Minor or Major Violations?
Collision Deductible:
$100
$200
$300
$250
$500
$1000
Comprehensive Deductible:
$100
$200
$300
$250
$500
$1000
Liability:
25/50/25
50/100/50
100/300/100
300/300/100
500/500/100
Uninsured / Underinsured Motorists:
25/50/25
50/100/50
100/300/100
300/300/100
500/500/100
Personal Injury Protection (PIP)/Med Pay
$2,500 PIP
$2,500 Med
$5,000 PIP
$5,000 Med
$10,000 PIP
$10,000 Med
Rental?
Towing?
Life Insurance?
In school now?
Taking driver's ed?
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