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For: Tom Agent
Type: Auto |
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Garaging Zip Code: 90104 |
Contact Information
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Name: |
Jim Customer |
Email: |
jimc@emailforyou.com |
Address: |
123 Sample Lane |
Daytime Phone: |
(123) 234-0934 |
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Anywhere, CA 90012 |
Evening Phone: |
(123) 234-4523 |
Best Time to Contact : |
Afternoon |
Mobile Number: |
(123) 690-6574 |
Addtional Comments: |
I need this quote ASAP! |
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Insurance and Liability Information
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Currently Insured: |
Yes |
Needs Policy: |
Immediately |
Company: |
Nationwide |
Yrs at Current Residence: |
1-2 years |
Time with Company: |
6 months - 1 year |
Household Income: |
$50,001-$100,000 |
Prior coverage: |
5+ years |
Credit History: |
Good |
Policy Renews: |
June 15, 2004 |
Current Liability Limit: |
$100,000/$300,000/$50,000 |
Current Payment: |
$100 monthly |
Desired Liability Limit: |
$250,000/$500,000/$100,000 |
Own Home?: |
Yes |
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Emergency Roadside Svc: |
Yes |
Rental Reimbursement: |
No |
Medical Payments: |
$5,000 |
Uninsured Motorist Cvg: |
$250,000/$500,000 |
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Driver Information - Jim Customer
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Name: |
Jim Customer |
License #: |
AL 265879900 |
Relationship to Jim: |
Self |
License Status: |
Active |
Date of Birth: |
5/5/1974 |
Social Sec. #: |
910-28-2587 |
Gender: |
Male |
Age Licensed: |
17 |
Marital Status: |
Married |
Occupation: |
Attorney |
GPA, if student: |
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Education Level: |
Batchelor's Degree |
Driving Record - Jim Customer |
Accidents in the last 3 years: |
2/06/2005 |
Collision - No bodily injury |
Moving Violations in the last 3 years: |
None |
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Driver Information - Anne Customer |
Name: |
Anne Customer |
License #: |
AL 352685942 |
Relationship to Jim: |
Spouse |
License Status: |
Active |
Date of Birth: |
7/12/1974 |
Social Sec. #: |
908-25-6565 |
Gender: |
Female |
Age Licensed: |
16 |
Marital Status: |
Married |
Occupation: |
Student, getting doctorate |
GPA, if student : |
3.9 |
Education Level: |
Masters |
Driving Record - Anne Customer |
Accidents
in the last 3 years: |
None |
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Moving
Violations in the last 3 years: |
1/16/04 |
Minor Violation - Speeding < 10 miles over speed limit |
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Vehicle Information
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Vehicle: |
2005 Toyota Camry XLE 4-cyl |
Primary Driver : |
Jim Customer |
VIN: |
680F2142TB6529 |
Fuel Type: |
Gas |
Doors: |
4 |
Main Use: |
Commute to Work |
Distance to Work: |
15 miles |
Annual Mileage: |
13,000 |
Four Wheel Drive: |
Yes |
Security System: |
No |
Anti-Lock Brakes: |
Yes |
Anti-Theft Device: |
No |
Airbags: |
Yes |
Automatic Seatbelts: |
No |
Deductibles: |
$250 Comp. / $250 Coll. |
Leased/Owned: |
Owned |
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