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Versatile Management Group

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Working with prosperity on our mind to insure your peace of mind.

Auto Insurance

DRIVER INFORMATION

Driver #1

Name:                                                                 Social security number:  

Driver's License Number:State:Exp. Date:

Relationship to applicant:    Gender:      Marital status:    

Driver's age:                     What is this driver's primary vehicle?

If you do not need to add any additional drivers, please click here...

Driver #2

Name:                                                                 Social security number:  

Driver's License Number:State:Exp. Date:

Relationship to applicant:    Gender:      Marital status:    

Driver's age:                     What is this driver's primary vehicle?

If you do not need to add any additional drivers, please click here...

Driver #3

Name:                                                                 Social security number:  

Driver's License Number:State:Exp. Date:

Relationship to applicant:    Gender:      Marital status:    

Driver's age:                     What is this driver's primary vehicle?

If you do not need to add any additional drivers, please click here...

Driver #4

Name:                                                                 Social security number:  

Driver's License Number:State:Exp. Date:

Relationship to applicant:    Gender:      Marital status:    

Driver's age:                     What is this driver's primary vehicle?

Copyright (c) 2005 Versatile Management Group, LLC - All Rights Reserved

PERSONAL INFORMATION

First Name:  

Last Name:  

E-mail address:  

Daytime Phone Number:       May we contact you at this number during the day?

Alternate Phone Number:       Is this a 

Fax Number:  

How would you prefer to be contacted regarding your quote? 

If you would prefer to be contacted by phone, please let us know the best time to call. 

Address:  

City:   State: Zip code:  

Social Security number:  

Occupation:  

Date of birth:   Gender:

Do you currently own your home or rent? 

To help us supply you with the most accurate quote possible, please answer all sections applicable to the coverage you are inquiring about.  If you are unsure of anything, 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.

.

INSURANCE COVERAGE

What company are you currently insured with?

Policy Number:Policy term:Date of expiration:

What is your current rate?Why are you shopping for different coverage?

VEHICLE #1 INFORMATION

Year: Make: Model:

Vehicle ID# (VIN):

      

Primary driver: Annual mileage:

What is the primary use of this vehicle?  Percentage of Use:

How many miles one way?

Is the vehicle in any way modified or customized? If yes, please explain:

Is there any existing damage to the vehicle? If yes, please explain:

If vehicle is kept at an address other than that listed above, please indicate below:

Address:  City:    State:    Zip:

If you do not need to add any additional vehicles, please click here  

VEHICLE #2 INFORMATION

Year: Make: Model:

Vehicle ID# (VIN):

      

Primary driver: Annual mileage:

What is the primary use of this vehicle?  Percentage of Use:

How many miles one way?

Is the vehicle in any way modified or customized? If yes, please explain:

Is there any existing damage to the vehicle? If yes, please explain:

If vehicle is kept at an address other than that listed above, please indicate below:

Address:  City:    State:    Zip:

If you do not need to add any additional vehicles, please click here

VEHICLE #3 INFORMATION

Year: Make: Model:

Vehicle ID# (VIN):

      

Primary driver: Annual mileage:

What is the primary use of this vehicle?  Percentage of Use:

How many miles one way?

Is the vehicle in any way modified or customized? If yes, please explain:

Is there any existing damage to the vehicle? If yes, please explain:

If vehicle is kept at an address other than that listed above, please indicate below:

Address:  City:    State:    Zip:

If you do not need to add any additional vehicles, please click here

VEHICLE #4 INFORMATION

Year: Make: Model:

Vehicle ID# (VIN):

      

Primary driver: Annual mileage:

What is the primary use of this vehicle?  Percentage of Use:

How many miles one way?

Is the vehicle in any way modified or customized? If yes, please explain:

Is there any existing damage to the vehicle? If yes, please explain:

If vehicle is kept at an address other than that listed above, please indicate below:

Address:  City:    State:    Zip:

COVERAGE OPTIONS

Bodily injury liability:  \Property damage liability: 

Underinsured motorist-bodily injury: 

Underinsured motorist-property damage:  Medical-personal injury protection: 

Accidental death: 

COVERAGE DEDUCTIBLES

  Comprehensive Collision  Towing Coverage

  Deductible Deductible        Deductible

Vehicle #1 

Vehicle #2 

Vehicle #3 

Vehicle #4 

Do you have any other questions, comments or do you need any additional information regarding Automobile Insurance?  Please explain...

DRIVER HISTORY

Have you or any other driver in your household:

Driver #1Driver #2Driver #3Driver #4

Had a ticket in the last 3 years?

Had a license suspended or revoked in the last 6 years?

Had a financial responsibility filing in the last 6 years?

Made any claims in the last 5 years?

 

If you answered yes to any of the above questions, please explain:

Would you like information on other services provided by Versatile Management Group?  Click Here

Once you have completed the above application, please review your answers checking for accuracy. 

To send your information to a qualified representative, please click on the submit button below. 

You will be contacted once your information is reviewed.

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YesNo

Cell PhonePagerHome (evening calls only)

PhoneFaxE-mailMail

AMPM

MaleFemale

select one...SelfSpouseChildParentOther

select one...MaleFemale

select oneMarried SingleDivorcedWidowed

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select one...SelfSpouseChildParentOther

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select one...SelfSpouseChildParentOther

select one...MaleFemale

select oneMarried SingleDivorcedWidowed

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select one...SelfSpouseChildParentOther

select one...MaleFemale

select oneMarried SingleDivorcedWidowed

select one...vehicle 1vehicle 2vehicle 3vehicle 4

select one...SelfSpouseChildParentOther

select one...MaleFemale

select oneMarried SingleDivorcedWidowed

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select one...3 month6 month12 month

OwnRent

select one...Driver #1Driver #2Driver #3Driver #4

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YesNo

YesNo

select one...Driver #1Driver #2Driver #3Driver #4

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YesNo

YesNo

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YesNo

YesNo

select one...Driver #1Driver #2Driver #3Driver #4

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YesNo

YesNo

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select one...$50,000$100,000$250,000$500,000

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select one...$25$50$100$200Not Interested

select one...$25$50$100$200Not Interested

select one...$100$200$500$1,000

select one...$250$500$1,000

select one...$25$50$100$200Not Interested

select one...$100$200$500$1,000

select one...$250$500$1,000

select one...$25$50$100$200Not Interested

select one...$100$200$500$1,000

select one...$250$500$1,000