WWW.BAYSINSURANCE.COM

Annuities, Life Insurance, Long Term Care experts!   AUTO QUOTE-- E-Z FORM--PLEASE FILL OUT BELOW The field marked with (*) are required fields. * How many cars in household? [Select One]12345 or more VEHICLE #1: Year, Make & Model VEHICLE #1- Vehicle ID# (See your insurance card) VEHICLE #1: Primary Use of car? [Select One]PleasureTo WorkFor BusinessFarming VEHICLE #1: Miles to work (one-way)? [Select One]1-5 miles6-10 miles11-15 miles16-20 miles21-25 miles26-31 miles32 plus miles VEHICLE #2: Year, Make & Model: VEHICLE #2: Vehicle ID# (See your Insurance Card) VEHICLE #2: Primary Use? [Select One]PleasureWorkBusinessFarming VEHCILE #2: Miles to work? (one-way) [Select One]1 to 5 miles6 to 10 miles11 to 15 miles16 to 20 miles21 to 25 miles26 to 30 miles31 plus miles Additional Car(s) Info: * How many drivers in household? [Select One]12345 or more * Driver 1: First Name: * Driver 1- Last Name * Driver 1: Date of Birth (Month/Day/Year) Driver 1- Drivers License Number Driver 1: Primary Car Driven (Ex: Honda) Driver #2- First Name & Last Name: Driver #2- Date of Birth (Month/Day/Year) Driver #2- Drivers License Number Additional Driver(S) Info * ***Any traffic violations in household last 5 years? [Select One]YesNo * Any AT-FAULT accidents in the household?(Last 5 years) [Select One]YesNo * Current insurance company? * Insurance-When does your insurance expire? (Month-day-Year) * What is your current insurance premium? Current Coverages-Bodily Injury Liability Limits? [Select One]$20,000/$40,000$25,000/$50,000$50,000/$100,000$100,000/$300,000$250,000/$500,000Other Deductible? [Select One]$0$50$100$250$500$1000 Do you have car rental reimbursement? [Select One]YesNo Do you have Road Service? [Select One]YesNo * Contact Name (First & Last Name) * Street Address- * City & State * Zip Code * Home Phone Number (Include Area Code) Work Phone or Cell Phone E-mail Address Promo Code (If available)