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(916) 334-5773 phone 5805 Watt Avenue
North Highlands, CA 95660 (916) 334-5661 fax

Get an Auto Insurance Quote

Welcome to Big Dan's "Get An Auto Insurance Quote" page. Just fill in the blanks below and when you're done, click on the Submit button. Your quote will be in your e-mail box within 24 business hours.

We will use this information for quoting and contacting purposes only. We do not sell information to third parties.

TELL US ABOUT YOURSELF
I am a :
First Name:
Middle Initial:
Last Name:
Street Address :
City:
State:
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Email Address:
How Many Months Have You Maintained Un-interrupted Auto Insurance:
Housing:	Own Rent Live with Parents
If You Own, Which Insurance Co. and Expiration Date:
Own A Major Credit Card:	Yes No
DRIVER #1 INFO
Driver #1 Name
Years Licensed in CA
Years Licensed in US
Date of Birth (MM/DD/YY):
Gender:	Male Female
Marital Status:
# of Miles One Way to Work or School:
Number of Moving Violations For Last 3 Years:
Were You "At Fault" For An Accident Last 3 Years:	Yes No
If Yes,Were There Bodily Injuries:	Yes No
Number of Accidents Last 3 Years: (Include Details Below)
Number of DUI's Last 3 Years:
Need An SR-22:	Yes No
DETAILS SECTION For Additional Accidents: Indicate Chargeable or Non-chargeable Injury or Non-injury For Suspensions: Indicate Dates From and To

DRIVER #2 INFO
Driver #2 Name
Years Licensed in CA
Years Licensed in US
Date of Birth (MM/DD/YY):
Gender:	Male Female
Marital Status:
# of Miles One Way to Work or School:
Number of Moving Violations For Last 3 Years:
Were You "At Fault" For An Accident Last 3 Years:	Yes No
If Yes,Were There Bodily Injuries:	Yes No
Number of Accidents Last 3 Years: (Include Details Below)
Number of DUI's Last 3 Years:
Need An SR-22:	Yes No
DETAILS SECTION For Additional Accidents: Indicate Chargeable or Non-chargeable Injury or Non-injury For Suspensions: Indicate Dates From and To

DRIVER #3 INFO

Driver #3 Name

Years Licensed in CA

Years Licensed in US

Date of Birth (MM/DD/YY):

Gender: Male Female

Marital Status:

# of Miles One Way to Work or School:

Number of Moving Violations For Last 3 Years:

Were You "At Fault" For An Accident Last 3 Years: Yes No

If Yes,Were There Bodily Injuries: Yes No

Number of Accidents Last 3 Years:
(Include Details Below)

Number of DUI's Last 3 Years:

Need An SR-22: Yes No

DETAILS SECTION

For Additional Accidents:
Indicate Chargeable or Non-chargeable
Injury or Non-injury

For Suspensions:
Indicate Dates From and To

VEHICLE #1 INFO

Year:

Make:

Model:

VIN (optional):

Vehicle Used Mostly For: Pleasure Work
Deliveries Business

If Vehicle Is Used For Work or Business, Please Describe:

VEHICLE #2 INFO

Year:

Make:

Model:

VIN (optional):

Vehicle Used Mostly For: Pleasure Work
Deliveries Business

If Vehicle Is Used For Work or Business, Please Describe:

VEHICLE #3 INFO

Year:

Make:

Model:

VIN (optional):

Vehicle Used Mostly For: Pleasure Work
Deliveries Business

If Vehicle Is Used For Work or Business, Please Describe:

WHAT COVERAGE DO YOU NEED

Bodily Injury:

Property Damage:

Uninsured Motorist:

Uninsured Motorist Property Damage: Yes No

Medical Payments:

Comprehensive/Collision Deductibles:

On Which Vehicle(s) for Comp/Collision: Veh 1 Veh 2
Both

Towing: Yes No

Rental Reimbursements: Yes No

SUBMIT INFORMATION
(You only need to press Submit once)

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If there is a problem with this form, please call (916) 334-5773