CA Auto Insurance Quote Request
Please complete the intake form so we can shop for the best auto insurance option for you. All questions mandatory to ensure all underwriting questions are addressed. Thank you! ~Nick Ramirez (CA LIC #0K79987)
Legal Name of Driver
*As Shown Exactly On Your Drivers License*
Date of Birth
Drivers License Number
INCLUDE THE STATE ISSUED IF NOT CA ISSUED
Cell Phone Number
Please enter a valid cell phone number.
Email for DocuSign
For DocuSign Only
How Many Drivers On the Policy?
Just Me - Only 1 Driver
5 or more Drivers
VIN Number(s) of each vehicle
Separate EACH VIN with a comma
What company are you currently insured with?
If no active coverage, describe when your policy ended.
Current Odometer Reading of EACH vehicle
An odometer photo will be required later
Describe your daily commute…
Drive to work everyday
Work from home full time
Commute 2-3x per week
I'm a business owner so my commute varies
What is your Job Title?
If you work from home full time, confirm this
How long have you had your car?
Brand New Purchase aka Less Than 90 Days
6 Months to 1 Year
1 Year to 3 Years
3 Years or More
Are there people who live with you at your address that are not drivers?
Yes, I have children or people in the household that are not drivers.
No, only the people listed on this form are in the household as drivers.
In the LAST 5 YEARS, how many accidents or tickets have you had? Check ALL that apply. We will run reports to validate this information so be clear :)
None, I have a spotless record! (congrats, btw)
I have 1 At-Fault accident, no injuries
I have 1 At-Fault accident, with injuries
I have more than 1 At-Fault accident
I have 1 Not-At-fault accident
I have more than 1 Not-At-Fault accident
My car is currently...
Fully Owned, No Payments
Renters & Owners
I am currently a renter & YES, I want to bundle my renters insurance
I am currently a renter & I DO NOT want to bundle my renters insurance
I own property & YES, I want to bundle my home insurance
I own property & NO, I do not want to bundle my home insurance
Bonus points: Attached Proof of Current Coverage aka Policy Declaration Page
Drag and drop files here
Choose a file
Any special or important things we should know about your situation? Please feel free to elaborate here so we get the full picture. Thank you!
Submit to Nick for Review
Should be Empty: