Foster, Carlson & White Insurance Agency


Automobile Insurance Quote Request  

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.
Contact Information
First Name
Last Name
Address
City
State
Zip Code
Work Phone
Home Phone
Mobile
Fax
Email Address
Social Security Number
Current Policy Information
Are you currently insured?
Yes No
If No, why not? (i.e. first time insured, policy cancelled 3 month's ago, etc.)
If Yes, by what company?
Policy Expiration Date
Current Annual Premium
Driver Information
(please include all licensed drivers in your household)
Driver #1 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Driver #1)
DL# (Driver #1)
State (Driver #1)
Years Licensed (Driver #1)
Relation (Driver #1)
Date of Birth (Driver #1)
Sex (Driver #1)
M
F
Number of Tickets (Driver #1)
Marital Status (Driver #1)
Married
Single
Number of Accidents (Driver #1)
SR-22 filing (Driver #1)
Yes No 		DUI/DWAI - past 5 yrs (Driver #1)
Drivers Ed. (Driver #1)
Yes No 		Accident Prevention (Driver #1)
Yes No
Driver #2 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Driver #2)
DL# (Driver #2)
State (Driver #2)
Years Licensed (Driver #2)
Relation (Driver #2)
Date of Birth (Driver #2)
Sex (Driver #2)
M
F
Number of Tickets (Driver #2)
Marital Status (Drive #2)
Married
Single
Number of Accidents (Driver #2)
SR-22 filing (Driver #2)
Yes No 		DUI/DWAI - past 5 yrs (Driver #2)
Drivers Ed. (Driver #2)
Yes No 		Accident Prevention (Driver #2)
Yes No
Driver #3 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Driver #3)
DL# (Driver #3)
State (Driver #3)
Years Licensed (Driver #3)
Relation (Driver #3)
Date of Birth (Driver #3)
Sex (Driver #3)
M
F
Number of Tickets (Driver #3)
Marital Status (Driver #3)
Married
Single
Number of Accidents (Driver #3)
SR-22 filing (Driver #3)
Yes No 		DUI/DWAI - past 5 yrs (Driver #3)
Drivers Ed. (Driver #3)
Yes No 		Accident Prevention (Driver #3)
Yes No
Driver #4 Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name (Driver #4)
DL# (Driver #4)
State (Driver #4)
Years Licensed (Driver #4)
Relation (Driver #4)
Date of Birth (Driver #4)
Sex (Driver #4)
M
F
Number of Tickets (Driver #4)
Marital Status (Driver #4)
Married
Single
Number of Accidents (Driver #4)
SR-22 filing (Driver #4)
Yes No 		DUI/DWAI - past 5 yrs (Driver #4)
Drivers Ed. (Driver #4)
Yes No 		Accident Prevention (Driver #4)
Yes No
Vehicle Information
(please include all cars you or your family members own or lease)
Car #1 Informaton - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Year (Car #1)
Make/Model (Car #1)
Vehicle ID# (Car #1)
Body Style (Car #1)
Vehicle Lease? (Car #1)
Yes No 		Annual Mileage (Car #1)
Drive to School/Work? (Car #1)
Yes No 		Miles one way (Car#1)
Airbags? (Car #1)
None
1
2
Car Alarm? (Car #1)
Yes No
Anti-lock Brakes? (Car #1)
Yes No 		Comprehensive Deduct. (Car #1)
Rental Reimbursement (Car #1)
Yes No 		Collision Deductible (Car #1)
Towing & Labor (Car #1)
Yes No
Car #2 Informaton - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Year (Car #2)
Make/Model (Car #2)
Vehicle ID# (Car #2)
Body Style (Car #2)
Vehicle Lease? (Car #2)
Yes No 		Annual Mileage (Car #2)
Drive to School/Work? (Car #2)
Yes No 		Miles one way (Car #2)
Airbags? (Car #2)
None
1
2
Car Alarm? (Car #2)
Yes No
Anti-lock Brakes? (Car #2)
Yes No 		Comprehensive Deduct. (Car #2)
Rental Reimbursement? (Car #2)
Yes No 		Collision Deductible (Car #2)
Towing & Labor? (Car #2)
Yes No
Car #3 Informaton - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Year (Car #3)
Make/Model (Car #3)
Vehicle ID# (Car #3)
Body Style (Car #3)
Vehicle Lease? (Car #3)
Yes No 		Annual Mileage (Car #3)
Drive to School/Work? (Car #3)
Yes No 		Miles one way (Car #3)
Airbags? (Car #3)
Yes No 		Car Alarm? (Car #3)
Yes No
Anti-lock Brakes? (Car #3)
Yes No 		Comprehensive Deduct. (Car #3)
Rental Reimbursement? (Car #3)
Yes No 		Collision Deductible (Car #3)
Towing & Labor? (Car #3)
Yes No
Car #4 Informaton - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Year (Car #4)
Make/Model (Car #4)
Vehicle ID# (Car #4)
Body Style (Car #4)
Vehicle Lease? (Car #4)
Yes No 		Annual Mileage (Car #4)
Drive to School/Work? (Car #4)
Yes No 		Miles one way (Car #4)
Airbags? (Car #4)
Yes No 		Car Alarm? (Car #4)
Yes No
Anti-lock Brakes? (Car #4)
Yes No 		Comprehensive Deduct. (Car #4)
Rental Reimbursment? (Car #4)
Yes No 		Collision Deductible (Car #4)
Towing & Labor? (Car #4)
Yes No



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