Auto Quote Survey Sheet

Ford & Thomas Insurance Agency

How did you find our site?__________________________

The following must be filled in correctly to receive an accurate quote.

Policy Renewal Date: __________

Present Auto Insurance Company: ______________________________

Date Submitted: __________
Name: _________________________
Address:_________________________________________________
City:_________________________
Zip Code:_______________
County:___________________
Home Phone : __________
Work Phone : __________

Occupation:_________________________
Employer:_________________________
Number of years at present employment:_____
Have you had any financial problems in the last 5 years? ______

Auto accidents or violations within the last 5 years. Date and Description.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Any driver ever have insurance canceled or refused? _______
If so, why? ___________________________________________________________
____________________________________________________________________

Drivers License revoked or suspended? _____

Have you had any Claims within the last 3 years? _____
Date, Description _____________________________________________________
__________________________________________________________________________
Amount Paid __________

Auto’s Owned:

_	Year	Make	Model	Body type 2Dr-4Dr-P/U	Use of Auto Pleasure or Commute To work? How far?	Main Driver
1.	_	_	_	_	_	_
2.	_	_	_	_	_	_
3.	_	_	_	_	_	_
4.	_	_	_	_	_	_
5.	_	_	_	_	_	_
6.	_	_	_	_	_	_

Drivers: Name	Age	Sex M/F	Marital Status	Years Licensed	Credits
_	_	_	_	_	_
_	_	_	_	_	_
_	_	_	_	_	_

Any other drivers in the household?

Limits of Liability Desired

Bodily Injury:

$100,000/300/000 ____ $250,000/500,000____Optional Higher Limits_________

Property Damage:

$100,000____$300,000____$500,000____Optional Higher Limits_________

Medical Payments:

$1,000____$2,000____$3,000____$5,000_____

Deductibles:

Comprehensive i.e. Glass, Fire, Theft

$50____$100____$250____$500____$1,000_____

Collision:

$100____$250____$500____$1,000_____

Please fax this form to us at 804-261-7945

Or mail to:

Ford and Thomas Insurance Agency, Inc.
6809 Stoneman Road
PO Box 9640
Richmond VA 23228

To be used for the State of Virginia only.

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