One Stop Insurance Solutions

 Mr.      Mrs.     Mr. and Mrs.    Ms. 

 First Name  Middle Initial

  Last Name  

Street Address:           

Apt#                    

City:                                 

State:                   Florida  

Zip Code:           

             Driver #1 

Gender:           Male  Female    

Date of Birth:  Month Choose One January February March April May June July August September October November December Day 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 0000 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923

Marital Status:            Single/Divorced  Married Separated

(If married, don't forget to list the info on your spouse as driver #2. To get a "preferred" rate with us (and most companies), both drivers and cars must be insured on one policy.)

5 Year Driving Record (All tickets and accidents, fault or not at fault)  

CLICK HERE for definitions of minor and major violations.

No incidents within 5 years

Date of Incident #1: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

Date of Incident #2: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

Date of Incident #3: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

             Driver #2 

Gender: Male  Female   

Date of Birth:  Month Choose One January February March April May June July August September October November December Day 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 0000 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923

Marital Status:   Single/Divorced  Married Separated

Relationship to driver #1  N/A Child Spouse Other Relative Friend   

5 Year Driving Record (All tickets and accidents, fault or not at fault)  

CLICK HERE for definitions of minor and major violations.

No incidents within 5 years

Date of Incident #1: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

Date of Incident #2: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

Date of Incident #3: (mo/yr)   Type:  N/A At Fault Accident Not At Fault Accident Hit While Parked Serious Speed Minor Violation Major Violation

Current Insurance Company

Auto Insurance is currently in force? Yes  No

If no, date of cancellation (approximate is fine):

Name of Current Insurance Co*.:  

Expiration Date:  

How long have you been with this company? Choose One 6 months 1 Year 2 Years 3 Years 4 Years 5 Years 6 to 10 Years 11 to 20 Years 21 Years or longer

Current Policy includes bodily injury liability?  Yes   No

Insured with current or other carrier for prior 12 months continuously?  Yes  No

Your prior insurance company and expiration date is critical in preparing an accurate quotation. If you have insurance, Please do not leave this area blank. 

*We really don't care about who your current insurance company is unless it affects our underwriting guidelines. There are a very few companies that cater only to "bad" risks. Underwriting is different if you are currently with of one of these companies.  

        Car #1

Year:      

Model:  

(include XLT, LS etc if applicable.)

Car #2

Year:      

Model:  

(include XLT, LS etc if applicable.)

Limits Preferred: Liability
Bodily Injury/Property Damage

Limit Preferred:
Medical Payments

Limit Preferred:
Uninsured Motorists

10/20 25/50 50/100 100/300 250/500 No Uninsured Motorist  

Unstacked Stacked Don't Know

Collision Deductible

Car #1 Choose One $100 $250 $500 $1000 No Collision

Car #2 Choose One N/A (No 2nd Car) No Collision $100 $250 $500 $1000

Car #1 Choose One No Comprehensive No Deductible $100 $250 $500 $1000

Car #2 Choose One N/A (No 2nd Car) No Comprehensive No Deductible $100 $250 $500 $1000

Rental Reimbursement

Choose One None $20 per day for 30 days $30 per day for 30 days

Yes    No

Discounts

(Check all that apply)

55 and Retired   Defensive Driving Course     Good Student      

Claim& Accident free 3 years    Claim& Accident free 5 years 

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