Arax Insurance

Phone:

1.888.867.2050

Fax:
1.888.867.2050

Address:
6014 Reseda Blvd.
Tarzana, Ca 91356

Email:
araxins@yahoo.com

AUTO INSURANCE QUOTE

Personal Information
Name:
Zip:
Daytime Telephone:
Email Address:
Occupation:
College Degree(s)/Major:
May we contact you by phone:	Yes

Auto Insurance History

Insurance Company Name (not agency):

# of Years Continuous Coverage w/out 30 day lapse:

Policy Expiration Date:

/ /

Vehicle #1 Information

(include all cars you or your family members own or lease)

Year

Make

Model

Vehicle ID# (VIN)

Annual Mileage

Garaging Zip Code

Primary Vehicle Use:

# of Miles to School/Work?

(One Way)

Driver # 1 Information
(include all licensed drivers in your household)
Driver's Name:
Drivers License #:	State:
Relation:
Date of Birth:	/ /
Sex:
Marital Status:
# of years licensed:

Vehicle #2 Information

(include all cars you or your family members own or lease)

Year

Make

Model

Vehicle ID# (VIN)

Annual Mileage

Garaging Zip Code

Primary Vehicle Use:

# of Miles to School/Work?

(One Way)

Driver # 2 Information
(include all licensed drivers in your household)
Driver's Name:
Drivers License #:	State:
Relation:
Date of Birth:	/ /
Sex:
Marital Status:
# of years licensed:

Vehicle #3 Information

(include all cars you or your family members own or lease)

Year

Make

Model

Vehicle ID# (VIN)

Annual Mileage

Garaging Zip Code

Primary Vehicle Use:

# of Miles to School/Work?

(One Way)

Driver # 3 Information
(include all licensed drivers in your household)
Driver's Name:
Drivers License #:	State:
Relation:
Date of Birth:	/ /
Sex:
Marital Status:
# of years licensed:

Vehicle #4 Information

(include all cars you or your family members own or lease)

Year

Make

Model

Vehicle ID# (VIN)

Annual Mileage

Garaging Zip Code

Primary Vehicle Use:

# of Miles to School/Work?

(One Way)

Driver # 4 Information
(include all licensed drivers in your household)
Driver's Name:
Drivers License #:	State:
Relation:
Date of Birth:	/ /
Sex:
Marital Status:
# of years licensed:

Liability Limit for All Cars

Bodily Injury/Property Damage:

Uninsured Motorist/Bodily Injury:

Medical Payments :

Deductibles and Misc.
Car#	Comprehensive Deductible	Collision Deductible
1
2
3
4

Driver History

Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years

Driver Name

Date of Conviction

Type of Conviction

/ /

Please list ANY driver who has had license suspensions, revocations or DUI convictions below

Drivers Name

Date of Conviction

Description

/ /

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years

Drivers Name

Date

Bodily Injury

At Fault

/ /

Yes

/ /

Yes

/ /

Yes

/ /

Yes

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, such as additional drivers, vehicles, driver histories, etc..., please enter them here.