Request for an Automobile Insurance Quote

Please completely fill out the form below so that we may provide you with
an accurate automobile insurance quote.

Current Insurance Carrier   

Have you had continuous insurance for the last six months? Yes    No

How would you rate your credit? Fair    Good    Excellent

    Vehicle Information

Please fill out the following information about your vehicles.
 If you have more than 4 vehicles, please note in the comment section at the end of this form.

Coverage Information

Please fill out the following information about the insurance coverages you would
like for your policy.

Please choose which vehicles (if any) you would like Comprehensive Coverage on:

            Vehicle 1        Vehicle 2        Vehicle 3      Vehicle 4

Please choose which vehicles (if any) you would like Collision Coverage on:  

            Vehicle 1        Vehicle 2        Vehicle 3      Vehicle 4

First Party Benefits

Medical    $5,000 $10,000 $100,000 $50,000     Funeral Not Chosen $1,500 $2,500 Accidental Death Not Chosen $10,000 $25,000

Income Loss    Not Chosen $1,000 per month / $5,000 maximum $1,000 per month / $10,000 maximum    EMB    Yes    No

Tort Option    Full Tort    Limited Tort

Personal Information

Driver 1

Name DOB Gender Male Female Status Single Married Divorced Separated Widowed

Drivers License Number    State

Social Security Number     Any Children? No Yes

Driver 2

Name DOB Gender Male Female Status Single Married Divorced Separated Widowed

Drivers License Number    State

Social Security Number     Any Children? No Yes

Driver 3

Name DOB Gender Male Female Status Single Married Divorced Separated Widowed

Drivers License Number    State

Social Security Number     Any Children? No Yes

Driver 4

Name DOB Gender Male Female Status Single Married Divorced Separated Widowed

Drivers License Number    State

Social Security Number     Any Children? No Yes

Has any driver in the household had any accidents, tickets, violations or claims against
an insurance company in the last 5 years?  Yes    No

If yes, please list date and describe incidents:

Comment Section

Please list any comments below that you feel are important for us to determine the most accurate rate for you automobile insurance.  Also, please note any comments from information sections above.

How would you like to contacted- Phone Number    Email

Please click the submit button below to send your information to an agent of the
Albert Evangelista Insurance Agency Your information will be used
to process a quote only, and this quote will not bind coverage
nor issue a policy or contract.