Car Insurance Questionnaire

WELCOME TO ELITE COVERAGE - INSURANCE BROKERAGE & CONSULTING

WHERE WE CAN GUARANTEE YOU BETTER PRICES! Below is all the information we’ll need to quote your Lowering or New Policy. Please fill out form. If it doesn’t apply to you, leave blank. Please re-check before submitting. PLEASE READ ALL INFORMATION BEFORE SUBMITTING!
Name*

First NameMiddle NameLast Name
Birthday *

MonthDayYear
Date
Email
example@example.com
Address as shown on your STATE ID.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your STATE ID #?*
LOAD IMAGE OF STATE ID *FRONT**

MAKE SURE ITS CLEAR, UPCLOSE WITH NO LIGHT GLARE!
Cancelof
Make sure you re-check before submitting. PLEASE BE ADVISED THIS IS A SERVICE,

Lowerings starts at $225/$250 & up.

New Policies starts at $300+ or at value of 1st months insurance payment.

Prices may vary or are subject to change due to different factors for different individuals.

IF YOU BOOK A CONSULTING WITH US & GO SHOP AROUND WE COULD NOT GUARANTEE YOU THE SAME POLICY AS DISCUSSED. A service charge is still due.

Be ready to make payment on the your scheduled date , as stated this is a service.

Also be ready to supply us with any information you were not able to fill out above.

Thank you speak to you soon.
Do you currently have Geico? IF YOU DO, all you need is to provide your LOG IN information &/or POLICY NUMBER.
IF YOU DONT HAVE GEICO, what insurance do you currently have, if any? Please provide everything below if applies. [1]POLICY #, [2]CAR VIN #, [3]FINANCED OR LEASED (if financing please provide which bank is providing the loan), [4]PREVIOUS ACCIDENTS OR TICKETS, if any. *
How much are you currently paying monthly? *
If needed, do you have someone to join your policy for a better rate?
Make sure you re-check before submitting. PLEASE BE ADVISED THIS IS A SERVICE,

Lowerings starts at $225/$250 & up.

New Policies starts at $300+ or at value of 1st months insurance payment.

Prices vary or are subject to change due to different factors for different individuals.

IF YOU BOOK A CONSULTING WITH US & GO SHOP AROUND WE COULD NOT GUARANTEE YOU THE SAME POLICY AS DISCUSSED. A service charge is still due.

Be ready to make payment on the your scheduled date , as stated this is a service.

Also be ready to supply us with any information you were not able to fill out above.

Thank you speak to you soon.
Please note the date in which you’re available for a call. Also text (347) 491-7172 confirming your consultation date. Feel free to add another date you’re available. Thank you!
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WELCOME TO ELITE COVERAGE - INSURANCE BROKERAGE & CONSULTING