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CONTACT INFORMATION:















UNDERWRITING INFORMATION:


























































COVERAGE INFORMATION:
































Thanks for allowing us to quote your auto. May we also quote your

AUTO INSURANCE QUOTE REQUEST
By completing and submitting this form I have reviewed the privacy statement of the Harnist Insurance Agency and understand its content and hereby grant permission to utilize the information I provide to secure insurance proposals on my behalf.

Please note that required fields are in blue. Providing as much information as possible will ensure accurate pricing. Any indication of rates are subject to underwriting, verification of information, and acceptance by the insuring company.
If you have just submitted a quote form,
please check box, fill in your first and
last name and skip to underwriting information.
First Name:
Last Name:
Address: * *
City:
State: Zip:
E-Mail Address:

Add me to your e-mail list.
Day Phone:
Evening Phone:
Contact Preference:
Years at current address:
* *
(* * If less than six months, give full previous address in comments below)




Do you presently have insurance coverage?YesNo
If yes, the name of your company (not agent)
Are you being canceled or non-renewed
by your present company?YesNo


Vehicle
Year
Make
Model
Vehicle Indent. No. VIN
1
2
3
4


Vehicle
Vehicle use:
Annual
Mileage
Custom add
on Equipment
1
* *
2
* *
3
* *
4
* *
(* * If yes, please describe and give value in comments.)

Driver 1
Driver 2
Driver 3
Driver 4
Name

License number:

License number:

License number:

License number:
Sex
Date of
Birth
Years
Licensed
Full time
Student
YesNo
YesNo
YesNo
YesNo
Away at
school

With car?
YN
Distance?

With car?
YN
Distance?

With car?
YN
Distance?

With car?
YN
Distance?
Gd.Student
B average
Marital
Status
Accidents
or Losses
Last 5 yrs
Yes * *
No
Yes * *
No
Yes * *
No
Yes * *
No
Tickets
Last 5 yrs
Yes * *
No
Yes * *
No
Yes * *
No
Yes * *
No
(* * If yes, give full details in comments below, including dates, ticket or
accident, and brief description)



Bodily injury limit - all vehicles (,000's):
**
Property damage limit - all vehicles (,000's):
Medical payment limit - all vehicles (,000's):
Uninsured / Underinsured Motorist -
all vehicles (,000's)
** Single limit liability includes both bodily injury and property damage in one limit.

Vehicle
Comprehensive/
Other than Collision
Deductible
Collision
Deductible
Towing
Car Rental
Daily limit
(30 day max.)
1
2
3
4

COMMENTS
Please provide any additional information you feel necessary for us to assess your insurance needs.


If you have interest in other forms of insurance, please check all that apply.
Life
Health
Disability
Long Term Care
Boat / Jet Ski
Flood Ins.
Investment Properties
Recreational Vehicles

This form will be sent directly to our agency in the form of an e-mail. The information you have provided will only be used for the purposes of securing a proposal of insurance. A licensed insurance agent will consult with you to determine the best plan of insurance to meet your needs. No coverage is implied and there is no obligation to you, our agency, or the companies we represent. Thank you for your interest in our services.