Questionnaire | Tim Shaw Insurance Group of Fort Myers Florida

Auto Quote - Tim Shaw Insurance - 239-939-1010
In order to quote your new, or requote your existing, Automobile Insurance, we will need the following information to accurately quote your coverage. We have several companies writing Auto Insurance, and we want to get you the absolute, rock bottom quote with every discount you qualify for. In order to do that, this information is necessary, as well as a COPY OF YOUR CURRENT AUTO DECLARATION (DEC) PAGE. If you can supply this information, I will immediately go to work for you.

Name

Phone Number

###

####

Email

Who told you about us?*

Address

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

1. List ALL drivers (even if insured elsewhere)
IN THE HOUSEHOLD, including names, dates of birth,
drivers license #'s, and state issued:*

2. Social Security # of Primary driver:

3. All Drivers Occupations (please be specific):*

4. All Drivers highest degree of education:*

5. Use of each vehicle (be specific, ex: to work
4 miles one way; to school 8 miles one way, etc.):*

6. Please list the Primary Driver for each
vehicle:*

7. Is any vehicle used in any type of business?*

Yes

..... If yes, please describe specifically:

8. Are vehicles owned or leased?*

Owned

Leased

9. Does any vehicle have a lienholder?

Yes

..... If yes, which one(s)?

10. What company are you currently insured with?

..... How long have you been insured with your
current carrier?

11. Any bankruptcies or foreclosures in the past 7
years

12. Who insures your home your home?

Do you carry Umbrella Liability?*

A copy of your current dec page (if no
attachments, please leave blank)

800.711.3305

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