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March 2, 2021
ABOUT PINECREST INSURANCE
OUR CARRIERS
INSURANCE PRODUCTS
Personal
Homeowner
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Landlord Property
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Personal Umbrella
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Recreational Vehicle
Motorcycle/ATV
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Boat/PWC
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RV
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Commerical
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Auto Quote
How Did You Hear About Us?
How did you hear about us?
I am a current Pinecrest Customer
Referred by a Friend
Web Search
Phone Book
Other
Insured Information
Insured Name *
Address *
City *
State
California
Zip Code *
Home Phone
Work Phone
Cell Phone
Email
Preferred Contact
Home Phone
Work Phone
Cell Phone
Email
Current Insurance
Do you presently have Auto Insurance?
Yes
No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past 3 years? *
Yes, Please provide reason
No
Licensed Drivers
1. (Primary Driver)
License State (California Only) *
CA
Gender
Male
Female
Marital Status
Married
Single
Divorced
Widowed
Relationship to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
Name on License (Driver #2)
License State
Gender
Male
Female
Marital Status
Married
Single
Divorced
Widowed
Relation to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
(last 5 years)
Coverages
Bodily Injury Liability
25/50
50/100
100/300
250/500
Property Damage Liability
25,000
50,000
100,000
Medical Payments
1,000
2,500
5,000
Uninsured Motorist Liability
25/50
50/100
100/300
250/500
Uninsured Motorist Property
25,000
50,000
100,000
Underinsured Motorist Liability
25/50
50/100
100/300
250/500
Underinsured Motorist Property Damage/Collision Deductible Waiver
Yes
No
Comprehensive Deductible
No Coverage
250
500
1,000
Collision Deductible
No Coverage
250
500
1,000
Rental Reimbursement
Yes
No
Towing & Labor
Yes
No
Other Drivers
Please provide the names and birthdates of any other residents in your household licensed to drive.
Name
1.
2.
3.
Vehicle(s) Information
1.
Year
Make
Model
VIN *
License State
Vehicle Use *
Pleasure
To/From Work or School
Business
Miles One Way to Work/School
Annual Mileage *
Current Odometer Reading
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
Year (Vehicle #2)
Make
Model
VIN *
License State
Vehicle Use
Pleasure
To/From Work or School
Business
Miles One Way to Work or School
Annual Mileage
Current Odometer Reading
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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