Marcus Group

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Personal Automobile

Instructions: Click on the section to enter/edit your information.

Step 1. Personal Information

Name:
Address:
City:
State:	(Note: We insure in Florida only)
Zip:
Do you own Your Home?:
Day Phone:
Beeper:
Eve. Phone:
Cell Phone:
E-mail Address:
Best Time To Contact:	AM PM
Method of contact:

Step 2. Current Policy Information

Do you presently have insurance:
If Yes, How long have you had this Insurance?:	Years: Months:
Insurance Co. Name:
Policy Expiration Date:
Currently Paying (6 months):	$

Step 3. Driver Information

	Driver 1	Driver 2	Driver 3	Driver 4
Name:
Relationship to Driver 1:
Occupation:
Length of Time at This Job:
Date of Birth:
Sex:	Male Female	Male Female	Male Female	Male Female
Marital Status:
If This Driver is 21 Years Old or Younger:
Has he/she Completed Driver's Education?	Yes No N/A	Yes No N/A	Yes No N/A	Yes No N/A
Is he/she a Student with a "B" Avg or Better?	Yes No N/A	Yes No N/A	Yes No N/A	Yes No N/A

Tickets and Accidents in the Past Five Years
Driver 1
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Date(s) of Accidents/Tickets:
Driver 2
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Date(s) of Accidents/Tickets:
Driver 3
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Date(s) of Accidents/Tickets:

Driver 4
Incident 1:	Incident 2:
Incident 3:	Incident 4:
Date(s) of Accidents/Tickets:
If you answered "Other Moving Violations" please give details below:

Step 4. Vehicle Information & Liability Limit For All Cars

Number of Vehicles in your Household:
	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Year:
Make:
Model:
Number of Doors:
Name of Primary Driver:
Is this Vehicle Leased?
How is Vehicle Primarily Driven?:	Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Vehicle Identification Number: (17 digits)
Miles to Work (One Way):
Average Annual Mileage:
Airbags:
Anti-Lock Brakes:	Yes No	Yes No	Yes No	Yes No
Car Alarm:

Liability Limit for All Cars

Bodily Injury Covers your legal liability for bodily injury claims brought against you.
Property Damage Covers your legal liability for property damage claims brought against you.
Uninsured Motorist Provides coverage when you are injured in an accident caused by another person who either has no insurance, or does not have enough insurance to cover your damages.
Personal Injury Protection (PIP) Provides coverage for your own personal injuries, without regard to fault.
Medical Payments Covers the medical expenses for injuries sustained by you, resident relatives, and other people in your auto as the result of an accident.
Comprehensive Deductible Pays for damage to your auto and its equipment not caused by a collision or upset.
Collision Deductible Pays for damage to your auto and its equipment caused by collision or upset.
Rental Car Assistance
Towing Assistance

Step 5. Additional Comments (optional)

Additional Information Section
In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages extenuating circumstances, etc.

How did you hear about us?

Step 6. Submit Information

After submitting your quote request, we will contact you the same/next business-day, after we have shopped among all of our carriers to find you the lowest possible rate.