Automobile Insurance Quote
Property Crossing is licensed
to sell insurance only in the state of Texas.
I. APPLICANT INFORMATION
NOTE: If you have more than 2
drivers and/or 2 vehicles, you will have the opportunity to enter
that information by clicking the appropriate button at the bottom of
this form.
Please fill in all the required
fields.
| First Driver |
Second Driver |
First Name
Middle Name
Last Name
Suffix if applicable)
Email
Home Phone
Business Phone
|
First Name
Middle Name
Last Name
Suffix if applicable)
Email
Home Phone
Business Phone
|
|
Vehicles
will be quoted at this address. Additional vehicles garaged at other locations may affect this quote. |
Street
City
State
Zip Code
|
Street
City
State
Zip Code
|
Date Of Birth
|
Social
Sec. No
|
Date Of Birth
|
Social Security
Number
|
Marital Status
|
SexFemaleMale |
Marital Status
|
SexFemaleMale |
Occupation
|
Occupation
|
| Do
you use your vehicle for work? Yes No |
Do
you use your vehicle for work? Yes No |
| Are
you a full time student? Yes No |
Are
you a full time student? Yes No |
Do
you currently Have Insurance? Yes No
How Long? |
Do
you currently Have Insurance? Yes No
How Long? |
| Are
you a homeowner? Yes No |
Are
you a homeowner? Yes No |
| Age
first licensed? yrs. |
Age
first licensed? yrs. |
|
|
|
Within the last 3
years, license suspended or revoked? |
| Yes No |
Yes No |
|
Within the last 3
years, number of traffic violations? |
|
|
|
Within the last 3
years, number of times cited for speeding 20 mph over the
speed limit? |
|
|
|
Within the last 3
years, number of times convicted of DWI? |
|
|
|
Within the last 5
years, number of times involved in an accident, regardless
of fault? |
|
|
|
Within the last 5
years, number of automobile insurance claims filed (other
than accidents listed above)? |
|
|
|
Within the last 5
years, number of times vehicle was stolen? |
|
|
|
Ever convicted of any
of negligent driving,
reckless driving, speed contest, or racing? |
| Yes No |
Yes No |
|
Ever convicted of any
of Open container, possession of alcohol, public
intoxication, or refusal to submit to breathalyzer test? |
| Yes No |
Yes No |
|
Ever convicted of any
of Hit and run? |
| Yes No |
Yes No |
|
Ever convicted of any
of Manslaughter? |
| Yes No |
Yes No |
|
Ever convicted of any
of Auto theft or any other felony? |
| Yes No |
Yes No |
|
Have your ever been
treated for Diabetes, epilepsy, physical impairment, or
deformity? |
| Yes No |
Yes No |
|
Have your ever been
treated for Mental illness? |
| Yes No |
Yes No |
II.
VEHICLE(S) INFORMATION
|
Vehicle
1 |
Vehicle
2 |
| Year |
|
|
| Make |
|
|
| Model |
|
|
| Body
Type |
|
|
| VIN
(Vehicle
Identification Number) - can be found on
your current Dec Page. |
|
|
| Who
drives this car? |
|
|
| How
is this car used? |
|
|
| Miles
driven to work or school (one-way)? |
|
|
|
. |
Auto
coverage desired: Please select the overages for your
quote |
| Bodily
Injury Liability |
|
|
| Property
Damage Liability |
|
|
| Medical
Expenses |
|
|
| Uninsured
Motorist Bodily Injury |
|
|
| Uninsured
Motorist Property Damage |
|
|
| Personal
Injury Protection (PIP) |
|
|
| Rental
Car Benefits |
|
|
| Towing
and Labor |
|
|
| Other
Than Collision (Comprehensive) Deductible |
|
|
| Collision
Deductible |
|
|
|
SUBMIT
How Do You Want To Be Contacted With The
Quote?
NOTE: Please select one method in which you
wish to be contacted, but YOU MUST ENTER A TELEPHONE NUMBER AND AN EMAIL
ADDRESS.
The rate quotes generated by this
program are estimates based on the information you have provided and
are not a contract, binder, or agreement to extend insurance
coverage. The coverage descriptions provided are general
descriptions of available coverages and are not a statement of
contract. All applications are subject to underwriting approval.
To provide an accurate quote, we require all information to be
completed. When processing the quote we utilize a credit score
system that assigns a numerical value to various items of
information. The information will not be shared with any
organization other than Property Crossing Insurance Agency, LLC and
its affiliates.
If you decide to purchase the policy, we will verify driving records
and other required information.
Notice of Information Practices
We collect nonpublic personal and financial information about you
from the following:
- Information we receive from you
on applications and other forms and directly from you;
- Information about your
transaction with us and our affiliates;
- Information we receive from
other insurers and from insurer databases;
- Information we receive from a
public or a consumer reporting agency.
We do not disclose any nonpublic
personal and financial information about our insureds or former
insureds to anyone, except as permitted by law. We may make
disclosures to affiliated or nonaffiliated third parties, as
applicable, without prior authorization as permitted by law.
We restrict access to nonpublic personal and financial information
about you to those employees who need to know that information to
provide service to you. We maintain physical, electronic, and
procedural safeguards that comply with Federal and State law to
guard your nonpublic personal and financial information.
CLICK
TO ACCEPT
If
you have additional drivers and/or vehicles to add, please click the
button below. Doing so will submit this initial information to us and
take you to another form for the additional information. Note that
all the required fields on this page must be completed prior to adding
the additional information.
If you do not need to add additional drivers and/or
vehicles, then please push the Submit button below and we will contact you
about your quote. Thank You.
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