Lee Insurance Concepts

Personalized protection for your business, family and future

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PERSONAL AUTO INSURANCE

Please fill out the information in the following form to get a quote for auto insurance.

Would you like to request an initial quote or apply for a policy?
Driver Information
First Name			Middle Initial
Last Name			Suffix
Gender			Date of Birth
Social Security Number			Marital Status
Drivers License #			State
Address			Suite/Apt
City			State
Zip			Home Phone
Cell Phone			Best day to contact
Your time zone			Best time to contact
Email
Occupation			Job Title
Employer			Employer Address
Click here to add additional drivers

Additional Drivers
Driver #2
First Name			Middle Initial
Last Name			Suffix
Gender			Date of Birth
Social Security Number			Marital Status
Drivers License #			State
Occupation			Job Title
Employer			Employer Address
Resident Considered Second Named Insured?
Driver #3
First Name			Middle Initial
Last Name			Suffix
Gender			Date of Birth
Social Security Number			Marital Status
Drivers License #			State
Occupation			Job Title
Employer			Employer Address
Resident Considered Second Named Insured?
Driver #4
First Name			Middle Initial
Last Name			Suffix
Gender			Date of Birth
Social Security Number			Marital Status
Drivers License #			State
Occupation			Job Title
Employer			Employer Address
Resident Considered Second Named Insured?

Policy Information
Policy Term
Select the Status of Current Insurance
Expiration Date of Current Policy
Number of Months Insured with Current Carrier
Select Type of Prior Coverage Liability Limits
Enter Prior Coverage Liability Limits
Accept EFT (Electronic Funds Transfer) as Billing Option:
With the exception of any encumbrances, are any vehicles not solely owned by and registered to the applicant?
Any car modified/special equipment? (include customized vans and pick-ups).
Any car kept at school?

Vehicle Information
Year	Make
Model	VIN
Cost New	Current Value
Type of Use	Commute Miles (one way)
Annual Miles	Garaged Address	Same as above As noted below
Address	Suite/Apt
City	State
Zip
Anti-Theft	Anti-Lock Brakes
Passive Restraint
Excess Electronic Equipment Coverage	Tapes, Records, Discs and Other Media
Limited Mexico Coverage	Auto Loan/Lease Coverage (Gap Coverage)
Click here to add additional vehicles

Additional Vehicles
Vehicle #2
Year	Make
Model	VIN
Cost New	Current Value
Type of Use	Commute Miles (one way)
Annual Miles	Garaged Address	Same as above As noted below
Address	Suite/Apt
City	State
Zip
Anti-Theft	Anti-Lock Brakes
Passive Restraint
Excess Electronic Equipment Coverage	Tapes, Records, Discs and Other Media
Limited Mexico Coverage	Auto Loan/Lease Coverage (Gap Coverage)
Vehicle #3
Year	Make
Model	VIN
Cost New	Current Value
Type of Use	Commute Miles (one way)
Annual Miles	Garaged Address	Same as above As noted below
Address	Suite/Apt
City	State
Zip
Anti-Theft	Anti-Lock Brakes
Passive Restraint
Excess Electronic Equipment Coverage	Tapes, Records, Discs and Other Media
Limited Mexico Coverage	Auto Loan/Lease Coverage (Gap Coverage)
Vehicle #4
Year	Make
Model	VIN
Cost New	Current Value
Type of Use	Commute Miles (one way)
Annual Miles	Garaged Address	Same as above As noted below
Address	Suite/Apt
City	State
Zip
Anti-Theft	Anti-Lock Brakes
Passive Restraint
Excess Electronic Equipment Coverage	Tapes, Records, Discs and Other Media
Limited Mexico Coverage	Auto Loan/Lease Coverage (Gap Coverage)

Coverage Information
Limit Choice			Combined Single Limits
Bodily Injury			Property Damage
Medical Payment
Single Uninsured Motorists (Includes Single Underinsured Motorists)
Split Uninsured Motorists (Includes Split Underinsured Motorists)
Other than Collision			Collision
Towing Coverage			Rental Coverage
Split Limit U.M. - P.D.			Single Limit U.M. - P.D.