Art Hollingsworth Insurance Services
Art Hollingsworth Insurance Services

Automobile Insurance Quote
We would like to provide you with a free, no-obligation automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please Note: This application is for California and Arizona Agents ONLY!

Agent Information
           Agent Name:
Phone: Fax:
Email Address:

 
Required*   Applicant acknowledges that a MVR/CLUE Report
MVR Report

Motor Vehicle Report: Your driving record (obtained from the state department of motor vehicles) helps determine how to set your rate, showing information about your driver license, traffic violations, and sometimes personal information.


CLUE Report

Comprehensive Loss Underwriting Exchange: Underwriters use the information in a CLUE report to rate insurance policies. An automobile CLUE loss history report provides insurance company names and policy numbers and any claim numbers. The report lists the dates of any claims, the loss types and amounts paid for losses, and it will tell if a claim was denied.
may be obtained during the quoting process

 
Personal Information
Name:
Address:
City:   State:   Zip:
Years at this Address:
Phone:
Email Address:

 
Current Auto Insurance Information
Company Name (not agency):
How long with this company/carrier?:
Policy Expiration Date:   Premium Amount: $
Term: 6 Months   1 Year   Other:

 
Vehicle Information
(include all cars you or your family members own or lease)
Car
#1
Year
Make
Model
Year Purchased
Body Type
Vehicle ID# (VIN)
Odometer
Annual Mileage
Drive to school/work?
# of miles
(one way)
  Airbags  
Car Alarm
Y N
Y   N
Y   N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:
Comprehensive Deductible
Collision Deductible
Towing
Loss of Use
Y   N
Y   N

  Click to Add Another Vehicle  

(Add up to 6 cars)

 
Liability Limit For ALL Cars
Choose either   Bodily Injury, Medical Payment, and Property Damage
or   Single Limit
Bodily Injury
        
Medical Payment
        
Property Damage
Single Limit

 
Driver Information (include all licensed drivers in your household)
Driver
#1
Driver's Name
Occupation
Drivers License Information
DL#: State: Yr's Licensed:
Relation
Date
of Birth
Sex
Marital
Status
4Yr College
Degree
Driver's
Education
Accident
Prevention
M F
M S
Y N Y N Y N
List ANY convictions for moving traffic violations (tickets) in the past 3 years
Date
Type of Conviction
Fines
Speed Over Limit
$
mph
$
mph
List ANY DUI convictions, license suspensions, or revocations in the past 7 years
DUI Conviction For Alcohol:
DUI Conviction For Drugs:
License Suspended
License Revoked
Y   N
Y   N
Y   N
Y   N
List ANY accidents, regardless of fault, in the past 5 years
Date
Description
Injuries
At Fault
Cost
Fines
N
$
$
N
$
$

  Click to Add Another Driver  

(Add up to 6 drivers)

 
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

 
Form Submission
Please review all information you entered above for accuracy prior to submission.

 I have reviewed all information that I have entered for accuracy.
  (Box must be checked before request can be sent)

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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