Le Claire Insurance

J L Le Claire & Sons Insurance Agency

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Antique Auto

Antique Auto Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Named Insured * Required
*Last Name
*First Name
*Street Address
*City
*State
*Zip Code
Phone Number
Social Security Number
*Email Address
Garaging Address - if different from above
*Street Address
*City
*State
*Zip Code
Driver 1 Information
*First Name
*Last Name
*Gender	Male Female
*Marital Status
Years Licensed
State Licensed
Relationship to Insured
Driver 2 Information
*First Name
*Last Name
*Gender	Male Female
*Marital Status
Years Licensed
State Licensed
Relationship to Insured
Driver 3 Information
*First Name
*Last Name
*Gender	Male Female
*Marital Status
Years Licensed
State Licensed
Relationship to Insured
Driver 4 Information
*First Name
*Last Name
*Gender	Male Female
*Marital Status
Years Licensed
State Licensed
Relationship to Insured
Vehicle 1 Information
*Type of Vehicle
*Year
*Make
*Model
*ID Number/VIN
*Value
*Vehicle Status (Stock or Modified)
*Is this vehicle secured in a locked garage?	Yes No
*Miles per Year
Ownership
Vehicle 2 Information
*Type of Vehicle
*Year
*Make
*Model
*ID Number/VIN
*Value
*Vehicle Status (Stock or Modified)
*Is this vehicle secured in a locked garage?	Yes No
*Miles per Year
Ownership
Vehicle 3 Information
*Type of Vehicle
*Year
*Make
*Model
*ID Number/VIN
*Value
*Vehicle Status (Stock or Modified)
*Is this vehicle secured in a locked garage?	Yes No
*Miles per Year
Ownership
Vehicle 4 Information
*Type of Vehicle
*Year
*Make
*Model
*ID Number/VIN
*Value
*Vehicle Status (Stock or Modified)
*Is this vehicle secured in a locked garage?	Yes No
*Miles per Year
Ownership
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)********
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Coverage Information*********
Bodily Injury/Property Damage (Single Limit)
Uninsured Motorist / Bodily Injury
Uninsured Motorist / Underinsured Motorist (Increase limits of above coverage)
Medical Payment
Miscellaneous Information
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments