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Summit Risk Advisors
Mark McGinnis, agent
mark@summitriskadvisors.com
{office} 770-386-7859
{fax} 678-619-2110
650 Henderson Drive, Suite 407
Cartersville, GA 30120
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Auto Insurance Quote
(*) Name and at least one contact number is required to submit quote form.
Name *
Physical Address
City
State
Zip
Mailing Address
City
State
Zip
Home Phone *
Work Phone
Email (requested)
Have you had continuous coverage for at least 12 months?
Yes
No
If not, why not?
Present Auto Insurance Company
Renewal Date
Own Home?
Yes
No
Car#1
Year
Make
Model
2dr/4dr
Miles to Work (one way)
Annual Mileage
Type of Anti-Theft Device on Vehicle
Vin #
Car#2
Year
Make
Model
2dr/4dr
Miles to Work (one way)
Annual Mileage
Type of Anti-Theft Device on Vehicle
Vin #
Car#3
Year
Make
Model
2dr/4dr
Miles to Work (one way)
Annual Mileage
Type of Anti-Theft Device on Vehicle
Vin #
Driver #1 Information
Driver Name
Occupation
Length at Current job
Highest Level of Education
Date of Birth
Drivers License Number
Social Security Number
Many of the companies we represent require this information prior to quoting.
Gender:
Male
Female
Marital Status
Single
Married
Divorced
Moving Violations in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each violation.
Accidents in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each accident.
Driver #2 Information
Driver Name
Occupation
Length at Current job
Highest Level of Education
Date of Birth
Drivers License Number
Social Security Number
Many of the companies we represent require this information prior to quoting.
Gender:
Male
Female
Marital Status
Single
Married
Divorced
Moving Violations in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each violation.
Accidents in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each accident.
Driver #3 Information
Driver Name
Occupation
Length at Current job
Highest Level of Education
Date of Birth
Drivers License Number
Social Security Number
Many of the companies we represent require this information prior to quoting.
Gender:
Male
Female
Marital Status
Single
Married
Divorced
Moving Violations in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each violation.
Accidents in Last 3 Years
0
1
2
3
Please provide the date and a brief description of each accident.
Liability Limit for All Cars
Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury
Property Damage
Single Limit
choose one
25,000/50,000
25,000
60,000
50,000/100,000
50,000
100,000
100,000/300,000
100,000
300,000
250,000/500,000
500,000
250,000
Levels of current Uninsured Motorist coverage
Car #1
Deductible Comprehensive
100
250
500
Deductible Collision
250
500
1000
Tow
Yes
Loss of Use
Yes
Car #2
Deductible Comprehensive
100
250
500
Deductible Collision
250
500
1000
Tow
Yes
Loss of Use
Yes
Car #3
Deductible Comprehensive
100
250
500
Deductible Collision
250
500
1000
Tow
Yes
Loss of Use
Yes
Comments
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