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HATFIELD INSURANCE
AGENCY


Auto Quote Questionnaire

Name:

Address:

City:

State:

Zip:

Phone:



Auto Information
Year
Make
Model
ID #
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4


Vehicle Usage
Usage
If Commute, Mileage One Way
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4


Driver Information
Name
D.O.B.
Soc. Sec. #
Oper. Lic. #
Driver 1
Driver 2
Driver 3
Driver 4


Coverage
Current Limits shown on policy
Liability Limit
Collision ded.
Comprehensive ded.
If possible please fax copy of the declaration page of your policy showing limits, autos, etc. to us at 203-256-5666.


Driver Record
Describe tickets/accidents last 3 years for drivers above:

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