Kasmer Insurance Agency, L.L.C.: Auto Quotes


Effective Date:
Your Name:
Current Address:	Street	Prior Address: (If less than 2yrs at current address)	Street
	City, State & Zip		City, State & Zip
Phone:		Please call me with quote premium. Please send quote via e-mail.
Email:

Current coverage:

Company:

Expiration Date:

Liability Limits:

Liability Limits and Coverages: Please select the coverages and limits that are to apply to your vehicles.
Bodily Injury
Property Damage
Medical Payments
Uninsured Motorists
UM Property Damage
Additional information:

Driver Information:
If there are more than four drivers, please call our office for a quote.

Driver 1:
Name
DOB
Sex
Marital Status
Soc Sec #	*
Drivers Lic #	*
Occupation
Accidents or violations in the past 3 years:
Good Student Discount
At School over 100 miles away.

Driver 2:
Name
DOB
Sex
Marital Status
Soc Sec #	*
Drivers Lic #	*
Occupation
Accidents or violations in the past 3 years:
Good Student Discount
At School over 100 miles away.

Driver 3:
Name
DOB
Sex
Marital Status
Soc Sec #	*
Drivers Lic #	*
Occupation
Accidents or violations in the past 3 years:
Good Student Discount
At School over 100 miles away.

Driver 4:
Name
DOB
Sex
Marital Status
Soc Sec #	*
Drivers Lic #	*
Occupation
Accidents or violations in the past 3 years:
Good Student Discount
At School over 100 miles away.

Household Members: (Non-Drivers)
Name:	D.O.B.	Relationship:	Insurance Carrier:	Policy Number:

Comments:

Please use the box below to enter any additional information you feel should be considered:

Agreement & Disclaimer

Thank you for requesting a quote from our agency. We are pleased to provide you with multiple ways to communicate your insurance needs to us, however please note:
Coverage via this online request is NOT bound until you have received a written acknowledgement from our office.
*Protecting your privacy and identity is very important to us. Your Social Security number is required to complete a quote. You can send it to us securely by entering it on this form, however we will contact you personally if you prefer to omit this information online.
- Please be aware that we may use your social security number to run a credit check. We may also run an MVR (motor vehicle report) and a CLUE report of loss information. These reports are necessary for any and all insurance quotes we provide either online or in person.
By clicking "Submit" you acknowledge that you understand and agree to this information.

Security test.
Please identify the picture:

Please identify this picture. For our visually impaired customers, please email us directly at contact at vortexdesign dot com.