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CGA Associates Automobile Insurance Quote
For the fastest and most accurate automobile insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!  

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:
Insured Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone:

Current Automobile Insurance Company (not agency):
Company Name:
Policy Exp. Date: / /
Premium: $
Term: 6 Months   1 Year   Other  

Vehicle Information:
(include all cars you or your family members own or lease)
Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Car #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:

Driver Information:
(including all licensed drivers in your household) // first driver //second driver // third driver // fourth driver
Driver's Name Occupation Relation
to you		 Date of birth
(Mo/Day/Yr)		 Male/
Female

M / F

Married/
Single

M / S

Completed # of Yrs.
Licensed		 % of Vehicle Use
Drivers
Education
Course		 Accident
Prevention
Course		 #1 #2 #3
Self M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
Must add to:   100% 100% 100%

Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
    Yes   No
    If yes, please answer the following:

// driver 2 // driver 3 // driver 4
Driver Date Type of Conviction Time Fines Speed
Over Limit
/ / $ MPH
/ / $ MPH
/ / $ MPH
/ / $ MPH

2. Had his/her license suspended or revoked?
    Answer only if "yes":
Driver Suspended Revoked
Yes Yes
Yes Yes
Yes Yes
Yes Yes

3. Been convicted of driving under the influence of alcohol or drugs?
    Answer only if "yes":
Driver Alcohol Drugs
Yes Yes
Yes Yes
Yes Yes
Yes Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
    Yes   No
    If yes, please answer the following:
// second accident
Driver Date Cost Fines Injuries At Fault Time Description
/ / $ $ Y
N		 Y
N
/ / $ $ Y
N		 Y
N
/ / $ $ Y
N		 Y
N
/ / $ $ Y
N		 Y
N

Additional Comments:
Please give any additional comments about the coverage you desire:

 
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