california auto insurance

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california auto insurance
 
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On-Line Non Owners
Auto Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Street Address:
City:
State: MUST be California!
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No If YES to SR22 filing, why needed?
(list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?

NON-OWNER INFORMATION
To Purchase Non Owners Insurance, you CANNOT own a vehicle. Please type in box - "I do NOT own a vehicle" to verify you understand.

Approximate Annual Mileage You Drive Non Owned vehicles:
 

Do you use rental vehicles or drive in business?
(Explain, if yes):
 
NON OWNER COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD $25/50 BI / 25 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
 
Comments or Remarks:
(List additional drivers, autos, etc. here)

Send my quotation via: E-Mail Fax
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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me an Auto Quote NOW!

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You may contact our agency at the address and phone numbers below:
 
Kostyo Insurance Agency
 4456 Vandever Avenue, Suite 10 - San Diego, CA 92120
Phone: 1-619-325-3600 / Toll-Free: 1-888-567-6985
Fax: 1-619-325-3606 / Lic# 0B55791
E-Mail us at: KIAINSURANCE@aol.com