Tanner - Ibbotson Inc.

Automobile Insurance
Let us provide a quote for you

We have several companies to work with. The more information we receive, the better job we will be able to do for you. Please complete the following questionnaire and we will get back to you with a quote. Be sure to complete all sections.

Please complete the following form. Bold fields are required.
Name
Street Address
City		State	Postal Code
Phone Number (Daytime)		Phone Number (Evening)
Email Address
Social Security Number:
Occupation:

Vehicles:
Make:	Model:	Year:	Use:	Miles, if used for work:	VIN:
Make:	Model:	Year:	Use:	Miles, if used for work:	VIN:
Make:	Model:	Year:	Use:	Miles, if used for work:	VIN:
Make:	Model:	Year:	Use:	Miles, if used for work:	VIN:
Drivers:
Name:	Date of Birth :	Marital Status:	License No:	Relationship to insured:
Name:	Date of Birth :	Marital Status:	License No:	Relationship to insured:
Name:	Date of Birth :	Marital Status:	License No:	Relationship to insured:
Name:	Date of Birth :	Marital Status:	License No:	Relationship to insured:

Accidents and Violations:
List accidents and violations from the last 4 years. Include Date, what happened, payout and driver's name:

Current Coverage:
Current Insurance Company		Company Name:
Bodily Injury		Coverage Per Person:	Coverage Per Accident:
Property Damage		Amount:
Uninsured / Underinsured motorist (UM/SUM)		Amount:	Coverage Per Accident:
Personal Injury Protection (PIP)		Amount:
Additional (PIP)		Amount:
Optional Basic Economic Loss		Yes No
Comprehensive Deductible		Amount:
Collision Deductible		Amount:
Death Benefits		Amount:
Towing		Amount:
Rental Cars		Coverage Per Day:	Coverage Per Accident:

Safety Features:
Anti Lock Brakes		Yes No
Air Bags		Yes No
Daytime Running Lamps		Yes No
Anti Theft Device		(Describe)
Auto Seat Belts		Yes No