Phillip R Davis & Associates

Physical address:
Phillip R Davis & Assoc Inc.
1623 W Centre Ave
Portage Mi. 49024

Mailing address:
Phillip R Davis & Assoc Inc.
P.O. Box 1836
Portage Mi. 49081-1836

Agency: 269.327.1622

Toll Free: 800.642.4431

Fax: 269.327.1673

prdavis@tds.net

Ashley Gibney

269.492.3156
Email Ashley

Melanie Littell

269.492.3157
Email Melanie

Nancy Nap

269.492.3158
Email Nancy

Michelle Clark

269.327.1622
Email Michelle

Automobile Insurance Quote Form

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 *Indicates a required field
*Full name:
*E-mail:
*Daytime phone:
Evening phone:
Fax:
How would you prefer to be contacted regarding your quote?			Phone Fax Mail Email
If you prefer to be contacted via phone, please let us know the best time to call.			AM PM
Address:
City:
State:
*Zip:
County:
Township:
Do you currently own your home or rent?	Own Rent
Driver's License Number::
Driver Information Driver #1
Name:
Relationship to applicant:					Self Spouse Parent Child Other
Sex:					Male Female
Marital status:					Married Single
Driver's birthdate:
Which vehicle does he/she drive? (See below for vehicle information.)					Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Percent use:					%
Driver #2
Name:
Relationship to applicant:					Self Spouse Parent Child Other
Sex:					Male Female
Marital status:					Married Single
Driver's birthdate:
Which vehicle does he/she drive?					Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Percent use:					%
Driver #3
Name:
Relationship to applicant:					Self Spouse Parent Child Other
Sex:					Male Female
Marital status:					Married Single
Driver's birthdate:
Which vehicle does he/she drive?					Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Percent use:					%
Driver #4
Name:
Relationship to applicant:					Self Spouse Parent Child Other
Sex:					Male Female
Marital status:					Married Single
Driver's birthdate:
Which vehicle does he/she drive?					Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Percent use:					%
Driver History
Company currently insured with (not agency):
Have you or any other driver in your household:
Had a ticket in the last 3 years?					Yes No
Had a license suspended or revoked in the last 6 years?					Yes No
Had a financial responsibility filing in the last 6 years?					Yes No
Had a felony conviction in the last 5 years?					Yes No
Made any insurance claims in the last 5 years?					Yes No
If you answered "Yes" to any of the above questions, please explain:
Vehicle Information Vehicle #1
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:					Driver #1 Driver #2 Driver #3 Driver #4
Annual mileage:
Is the vehicle driven to school or work?					Yes No
If driven to school or work, how many weeks per month?					days weeks
If driven to school or work, how many miles one way?					miles
Is the vehicle in any way modified or customized?					Yes No
Is there any existing damage to the vehicle?					Yes No
If the vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:
Vehicle #2
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:					Driver #1 Driver #2 Driver #3 Driver #4
Annual mileage:
Is the vehicle driven to school or work?					Yes No
If driven to school or work, how many weeks per month?					days weeks
If driven to school or work, how many miles one way?					miles
Is the vehicle in any way modified or customized?					Yes No
Is there any existing damage to the vehicle?					Yes No
If the vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:
Vehicle #3
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:					Driver #1 Driver #2 Driver #3 Driver #4
Annual mileage:
Is the vehicle driven to school or work?					Yes No
If driven to school or work, how many weeks per month?					days weeks
If driven to school or work, how many miles one way?					miles
Is the vehicle in any way modified or customized?					Yes No
Is there any existing damage to the vehicle?					Yes No
If the vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:
Vehicle #4
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:					Driver #1 Driver #2 Driver #3 Driver #4
Annual mileage:
Is the vehicle driven to school or work?					Yes No
If driven to school or work, how many weeks per month?					days weeks
If driven to school or work, how many miles one way?					miles
Is the vehicle in any way modified or customized?					Yes No
Is there any existing damage to the vehicle?					Yes No
If the vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:
Coverage Options
Bodily injury liability:					50,000-100,000 100,000-300,000 250,000-500,000
Property damage liability:					50,000 100,000 250,000 500,000
Uninsured motorist bodily injury liability:					50,000-100,000 100,000-300,000 250,000-500,000
Uninsured motorist property damage liability:					50,000-100,000 100,000-300,000 250,000-500,000
Medical coverage and work loss through employer?					Yes No
Accidental death?					Yes No
Coverage Deductibles Vehicle #1
Comprehensive deductible:					No coverage 100 250 500
Collision deductible:					No coverage 250 500 1000
Towing Coverage Limit:					No coverage 50 75 100
Rental Limit:					No coverage 20/day 30/day 50/day
Vehicle #2
Comprehensive deductible:					No coverage 100 250 500
Collision deductible:					No coverage 250 500 1000
Towing Coverage Limit:					No coverage 50 75 100
Rental Limit:					No coverage 20/day 30/day 50/day
Vehicle #3
Comprehensive deductible:					No coverage 100 250 500
Collision deductible:					No coverage 250 500 1000
Towing Coverage Limit:					No coverage 50 75 100
Rental Limit:					No coverage 20/day 30/day 50/day
Vehicle #4
Comprehensive deductible:					No coverage 100 250 500
Collision deductible:					No coverage 250 500 1000
Towing Coverage Limit:					No coverage 50 75 100
Rental Limit:					No coverage 20/day 30/day 50/day
Questions, comments, or additional automobile information:

© 2012 PR Davis & Associates | All rights reserved.