D.S.G. Douglas S. Gordon Insurance Services | Residential -Request a Quote

F.A.Q.

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Auto Quote Request Form
Please provide the following information and one of
our representatives will be in touch with you shortly.

Registration Information
Registered to:
Registered State:
City where garaged:
ZIP code where garaged (must be valid for city)
Garage type

Household Information
How many people living in your household will not be listed as drivers on your policy? (maximum of 9 household members)
Have you filed for bankruptcy, had any lawsuits or judgements against you, or bad adverse credit in the last 5 years?	Yes No
Have you or any member of your household been convicted of a misdemeanor in the last 5 years, or a felony in the last 10 years?	Yes No

Driving History
In which state are you licensed to drive?
Have you completed a defensive driver course in the last 3 years?
In the last 3 years has you license been suspended?revoked?	Yes No
Do you need to file a financial responsibility form? (SR-22)	Yes No
Have you been cited for any violations or involved in any accidents, regardless of fault, in the last 3 years, or experienced any losses in the last 3 years?	Yes No

Have you had any accidents in the last 5 years?
Driver	Violation Date	Violation Code	Violation Date	Violation Code
1

2

3

4

Coverage History
Have you ever had auto insurance coverage?	Yes No
Have you had continuous coverage for at least the last 12 months?	Yes No
Have you ever had comprehensive coverage?	Yes No
Have you ever had collision coverage?	Yes No
Who do you currently have insurance with?
How long have you been with this carrier?	Yrs. Mos
What is your current policy's expiration date?
In the last 3 years, has your insurance been canceled or have you been refused insurance?	Yes No

Desired Coverage, Select Your Limits
Bodily injury liability
Property damage liability
Medical payments
Uninsured and underinsured motorist bodily injury (cannot be higher than Bodily injury liability above)
Uninsured motorist property damage liability (applies if you have an insured vehicle without collision coverage)
Comprehensive deductible
Collision deductible (comprehensive coverage is required for collision coverage)
Rental reimbursement
Waiver of collision deductible (applies if you have insured vehicle with collision coverage)
Towing and Labor
Coverage start date Choose a desired start date for this policy Note: Coverage is not effective until you receive confirmation from the insurance carriers selected)