Harris - Auto Quote

Automobile Quote (Florida Only)

You will be contacted within 1 business day by our agent

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
Your Name:	First: Last:
E-Mail address:
Phone numbers:	Day Time:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	PhoneFaxEmail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:	(You must live in Florida)
Zip code:
Do you currently own your home, or rent?	RentOwn
Social security number: (optional but may improve premium)

INSURANCE HISTORY
Currently insured with (company name not agency):	Num of Months Coverage:	Date Expires:
Prior Policy Number:	Prior Bodily Injury Limits:

DRIVER HISTORY
Have you or any other driver in your household:
Had a ticket in the last 3 years?	Had a license suspended or revoked in the last3 years?	Had a financial responsibility filing in the last 3 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No
If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Is the vehicle in any way modified or customized?YesNo			Is there any existing damage to the vehicle?YesNo

VEHICLE #2 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Is the vehicle in any way modified or customized?YesNo			Is there any existing damage to the vehicle?YesNo

VEHICLE #3 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Is the vehicle in any way modified or customized?YesNo			Is there any existing damage to the vehicle?YesNo

VEHICLE #4 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Is the vehicle in any way modified or customized?YesNo			Is there any existing damage to the vehicle?YesNo

COVERAGE OPTIONS
Coverage Definition Bodily Injury Liability:
Property Damage Liability:
Uninsured Motorist:
Personal Injury Protection:
Medical Payments:

PHYSICAL DAMAGE			ADDITIONAL COVERAGE
	Comprehensive Deductible	Collision Deductible	Towing	Rental
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4