RK Hughes - Automotive Insurance

Automotive Coverage

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Please tell us about the Primary Driver:
*Primary Drivers First Name:
*Primary Drivers Last Name:
*Street Address:

*City:
County:
*State/ZIP:	ZIP
*Email Address:
*Daytime Telephone:
Evening Telephone:
Are you currently insured (or have you been within the past 30 days)?	Yes No
How long have you been continuously insured, not necessarily with your present insurance company?
When does your insurance expire? (example: 01/15/2002)
Who are you currently insured with?
How long have you been insured with your present insurance company?
College Graduate:
*Driver's License Number:
Select the state where you currently have a valid drivers license:
Driver Training:
Gender:
Marital Status:
Date of Birth: (example: 01/15/2002)
Has your license been suspended or revoked in the past 5 years?
Have you ever served in the U.S. Armed Forces?
At what age did you first receive a U.S. drivers license?

Please tell us about any Secondary Drivers:
Driver	First Name	Last Name	Date Of Birth (ex: 01/11/1961)	DUI/DWI (Past 5 years)
2nd:
3rd:
4th:

All Drivers:
Has any of the above drivers received any tickets or been involved in any accidents, regardless of fault, within the past 3 years?:		Yes No
Has any insurance company you have been insured with in the past 3 years paid any claims, regardless of type?:		Yes No

Please tell us about the Vehicle:
Year	Make	Model	Usage

	Above Average	500,000 Combined Single Limit
	Average	300,000 Combined Single Limit
	Below Average	100,000 Combined Single Limit
	State Minimum	35,000 Combined Single Limit
	State Basic	5,000 Property Damage 15,000 Per Person Medical

Information For Agents Supplying Quotes:
Best time to contact me:
Questions/Comments:

Please note: You must speak directly to a representative of our office to bind coverage. This quote form does not bind coverage.

� 2002 RK Hughes, Inc.

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