Affordable automobile insurance quote request form.

Mikkelsen Insurance Services

Information needed to furnish auto and motorcycle premium indication.

Available only for Alameda, San Joaquin and Stanislaus counties of California!

General Information: Please fill in all blanks, if the answer is not applicable put NONE or N/A. (Blank spaces may cause delays in response.) (Read our Privacy Statement)

Name:
Address:
City:	Calif. Zip code:
E-mail address:

Home Phone:

Work Phone:

Government Employee? Yes/No: Which? City, County, State or Fed.:

Date of Birth: Years licensed?: License #: Married, Single, or Student:

Any tickets or accidents? Please give details including dates:

Current Carrier: Exp. Date: Premium: $

Other Drivers In Household:

#2 Name:

Date of Birth:

Years licensed?:

Drive which car:

Any Tickets or Accidents? Please give details including dates:

#3 Name:

Date of Birth:

Years licensed?:

Drive which car:

Any Tickets or Accidents? Please give details including dates:

Vehicle Information:

Year:	Make:	Model and Sub-model:	VIN#s:	Value:
#1.
#2.
#3.

Annual Milage Driven, #1 #2 #3

Coverages:

Bodily Injury:	Property Damage:	Med.:

U/M Bodily Injury:	U/M Property Damage:	Comp.Ded.:	Coll.Ded.:

Towing? Yes No

Rental reimbursement? Yes No

Additional Information or coverages (For motorcycles please include information on cycle safety classes if any and number of years licensed as well as the CCs):


For a FREE quote please complete the form and press "Send" or if you prefer, you may print the form then fax to 209-839-8632.