At NEC Insurance Agency, Inc. We put the power of the internet to work for you! Please take a moment to answer the following questions. Remember, this information is needed to find the best the best rate for you, so please answer it as accurately and completely as possible.

1) Do you have automobile insurance now?  Yes No

2) What is the name of your current auto insurance company:

3) If not listed, please give company name:

4) Current liability limit:

5) How long, in years, have you had auto insurance with this company?

6) How long, have you continuously had auto insurance without a lapse in coverage?

7) When Does Your Policy Renew:

8) How much do you currently pay for your insurance? $

9) Number of drivers to be quoted:

Driver Information:
If there is more than one driver, please complete this form and enter info on 2nd driver on next page.

1) Name on Drivers License: (Last, First MI)

2) Drivers License Number:

State of Issue:

Date of Birth: [MM/DD/YYYY]

3) Social Security Number:

4) To get exact Quote, We have to run your Credit, Do you give us permission to do so ?  Yes No Just Estimate

5) Sex:  Male Female

6) Marital Status:

7) Occupation:

8) Years Licensed:

9) 6 hour accident prevention class ?  Yes No

Driving History: 1st driver history. Has this driver had any?

1) Any DUI or DWI in the Last 5 Years?  Yes No

2) Has your license been suspended in the last 5 years?  Yes No
or revoked?  Yes No

3) Number of moving violations in the last 4 years. (Speeding, Stop Sign, Etc.)

4) Number of Accidents in the last 4 years:

# of Points?

5) Total Fines received in the last 4 years:

6) Please detail ALL Violation (tickets) in the Last 4 years for primary driver. Please list the dates of the violations.

Vehicle Information:

1) Is the Vehicle Leased:  Yes No





2) VIN:

3) 4-Wheel Drive?  Yes No

4)Anti-Lock Brakes (ABS)?  Yes No

5) Alarm Type?

6) Number of Air Bags?

7)Seat Belts?


Zip of Parking:

9) Annual Miles:

10) Auto Use:

Miles to Work (1 Way)

11) Comprehensive Deductible:

12) Collision Deductible:

13) Please list all other vehicles you would like us to consider:

The following questions concern the type of auto coverage you are requesting. Please answer them as accurately as possible. Please Select From the Following:

1)Bodily Injury:

Property Damage Limit:

2) Uninsured Motorist Coverage:

3) Please indicate Which Features You Would Like:
 Medical Coverage Towing Coverage Rental Car Reimbursement Glass Coverage

The answer to these basic questions will help us process your information.

1) Do you own or rent your residence:

2) Best Time To Contact:    

3) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                

9. Zip Code: