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DLR Insurance Agency
PO Box 747
Clovis, CA 93613

Call: 888-207-2121 Or: 559-299-8888
Fax: 559-299-7723

E-mail Us At:
dlr-insurance@
pacbell.net

California
Insurance Lic#:
0627884

"All Our Policies Come With An Agent!"

 
On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Street Address:
City:
State: (Must be California)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Tell Us About Your Credit History (Excellent, Fair, Poor, etc?)
(Some carriers use credit history to qualify, this information is REQUIRED)

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No If YES to SR22 filing, why needed?
(list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD   $25/50 BI / 25 PD
$100/300 BI / 50 PD    $250/500 / 100 PD
$1 Million + (Quote Umbrella)
 
Comprehensive
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Rental Car &
Towing Coverage?		 YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD   $25/50 BI / 25 PD
$100/300 BI / 50 PD $250/500 / 100 PD
$1 Million + (Quote Umbrella)
 
Comprehensive Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Rental Car &
Towing Coverage?		 YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:

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