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Wells Insurance 309 US Hwy 27 South Lake Placid, Florida 33852 Get Map Sebring Office Phone: 863-465-7155 Fax: 863-699-1925 Email Us

ONLINE QUOTE FORM

Business & Commercial Auto Vehicle Insurance Quote
	Contact Name:
	Business Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
	Vehicle Information
	(List all cars you own/lease)
Vehicle 1:	Year	Make/Model	Vin #
	Yearly Mileage	Usage	Alarm
		Select.. Pleasure Work over 3 mi. Work less 3 mi. Business	Yes No
Vehicle 2:	Year	Make/Model	Vin #
	Yearly Mileage	Usage	Alarm
		Select.. Pleasure Work over 3 mi. Work less 3 mi. Business	Yes No
Vehicle 3:	Year	Make/Model	Vin #
	Yearly Mileage	Usage	Alarm
		Select.. Pleasure Work over 3 mi. Work less 3 mi. Business	Yes No
Vehicle 4:	Year	Make/Model	Vin #
	Yearly Mileage	Usage	Alarm
		Select.. Pleasure Work over 3 mi. Work less 3 mi. Business	Yes No
Any Custom equipment of vehicles? (if YES, give their value):
	Current Insurance Information
Insurance Company Name:
Policy Exp. Date:		Premium Amt:
Term:		How long with current?
Debris hauled for others?:		Yes No
	Trailer Hitch?:	Yes No
Liability Limit Requested:		Select.. $100,000 $300,000 $500,000 $1,000,000
Class of Business:
	Driver 1
Name:		Sex:	Male Female
DL #:		Marital Status:	Married Single
Date of birth:		Driver's Education?:	Yes No
S.S.# (optional):		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 filing?:	No Yes
	Driver 2
Name:		Sex:	Male Female
DL #:		Marital Status:	Married Single
Date of birth:		Driver's Education?:	Yes No
S.S.# (optional):		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 filing?:	No Yes
	Driver 3
Name:		Sex:	Male Female
DL #:		Marital Status:	Married Single
Date of birth:		Driver's Education?:	Yes No
S.S.#(optional):		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 filing?:	No Yes
	Driver 4
Name:		Sex:	Male Female
DL #:		Marital Status:	Married Single
Date of birth:		Driver's Education?:	Yes No
S.S.# (optional):		Defensive Driving:	Yes No
Years Licensed:		Good Student:	Yes No
Occupation:		SR 22 filing?:	No Yes
	Accidents / Violations in the last 5 years?
Date	Driver	Violation	Cost ($)
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed
		Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed
List any DUI convictions, license suspensions or revocations:
How did you hear about us?		Select Referral Internet Search Google Yahoo Bing Flyer/Brochure Phone Book Radio Spot Other
Any additional comments or information that might be helpful in your quote:
Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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