Auto Quote

Tencer Insurance Agency

Today the average automobile cost what many suburban homes did 30 years ago.
And, as expensive as it may be own and operate a vehicle, those costs would be insignificant compared to an uninsured or underinsured auto accident. Auto and recreational vehicle policies offer coverage for bodily injury, property damage, uninsured or underinsured motorist, medical expenses and physical damage to your own vehicle. In most states, including California, if you own a vehicle you are required by state law to carry liability insurance in case you injury someone or damage their property.

Automobile Quote Request Form
* = Fields marked with an asterisk must be filled out for all persons to be insured.

ITEM	YOURSELF	SPOUSE
Name (First, MI, Last): *
Years Licensed in US or Canada: *
Date of Birth: (mm/dd/yy) *
Occupation:
Please List Information on Other Drivers in your Household	ADDITIONAL DRIVER #1	ADDITIONAL DRIVER #2
Name (First, MI, Last): *
Years Licensed in US or Canada:*
Date of Birth: (mm/dd/yy) *
Occupation:

	VEHICLE #1	VEHICLE #2	VEHICLE #3
Manufacturer (Make): *
Year : *
Specific Model: * (Accord EX, Accord LX, etc.)
Zip Code Where Kept: *
Drive Wheels:
Commute (to work or school): *	Miles one way Days per Week	Miles one way Days per Week	Miles one way Days per Week
Approx. Annual Miles: (Not applicable to boats)
Used for business*	Yes No	Yes No	Yes No
Primary Driver:

If you have more than four drivers to be insured, check here and submit a second form or contact us directly.
If you have more than three vehicles to be insured, check here and submit a second form or contact us directly.
Motorcycles

Engine CCs * : How long have you had a Motorcycle license? * Years

Boat

Type of boat * : Engine Size * HP CCs
Length (feet) Approx. Top Speed (Power or Pontoon Boats) * mph

Motor Homes or Trailers

Length * Feet Trailers - Separate Braking System? Yes No
Trailer - Fifth Wheel? Yes No Trailers - Double Axle? Yes No

If you currently have insurance, with whom?

Company: How long?:

Coverage Desired *

           Liability Limits:      Uninsured Motorists :
   Medical Payments:       Comprehensive Deductible :
Collision Deductible :     Towing : Yes No
Rental Car Reimbursement : Yes No Other:

Traffic Violations *

Incorrect information will result in invalid quotes.

List any minor moving violations in the last 3 years? (stop sign violations, speeding tickets, etc...)
Which Driver?      Type of Violation:
Which Driver?      Type of Violation:
Which Driver?      Type of Violation:
Which Driver?      Type of Violation:

List Accidents, fault or non-fault, in ANY vehicle in last 3 years (including vehicles not listed).
Which Driver Reported to Police?: Yes   No
                                                                                Injuries? Yes No
Which Driver Reported to Police?: Yes No
                                                                                Injuries? Yes No
Which Driver Reported to Police?: Yes   No
                                                                                Injuries? Yes No

List any MAJOR violations ( DUI, Reckless Driving, etc.) or license
suspensions for any listed driver SINCE LICENSED.

#1. Which Driver    When
      Describe     DMV filing required?: Yes   No

#2. Which Driver   When
      Describe     DMV filing required?: Yes   No

#3. Which Driver   When
     Describe     DMV filing required?: Yes   No

Contact Information *

Best time to reach you?
E-mail address
Voice Phone
FAX

Larry Tencer, Agent/Broker
Larry Tencer Insurance (Website)
55 Maria Dr., Suite 840 Petaluma, CA 94954
707 763-7000
larry@tencerinsurance.com