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! ~Miles Agency (CA LIC #6005413)
Legal Name of Driver
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*As Shown Exactly On Your Drivers License*
Address
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Date of Birth
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Drivers License Number
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Drivers License State
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Cell Phone Number
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Please enter a valid cell phone number.
Format: (000) 000-0000.
Email for DocuSign
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For DocuSign Only
How Many Drivers On the Policy?
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Please Select
Just Me - Only 1 Driver
2 Drivers
3 Drivers
4 Drivers
5 or more Drivers
VIN Number(s) of each vehicle
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Separate EACH VIN with a comma
What company are you currently insured with?
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If no active coverage, describe when your policy ended.
Current Odometer Reading of EACH vehicle
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An odometer photo will be required later
Describe your daily commute…
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Drive to work everyday
Work from home full time
Commute 2-3x per week
I'm a business owner so my commute varies
Other
What is your Job Title?
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Employer Name
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Employer Address
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If you work from home full time, confirm this
How long have you had your car?
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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?
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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 :)
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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...
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Fully Owned, No Payments
Leased
Financed
Renters & Owners
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I own property & YES, I want to bundle my home insurance
I own property & NO, I do not want to bundle my home insurance
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
Bonus points: Attached Proof of Current Coverage aka Policy Declaration Page
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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!
Do you have a preferred agent in our office that asked you to fill out this form?
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Who referred you (I.E. Realtor, Lender, Family, Friend)? We'd love to reach out and say thank you!
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Submit to the Philip Miles Agency for Review
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