Mickey Clayton Insurance

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Please fill out the information below and we will send you a quote by e-mail.


Contact Information
Name: 
Street Address: 
Address (cont.): 
City: 
State/Province: 
Zip/Postal Code: 
Work Phone: 
Home Phone: 
Fax: 
E-mail: 
Method of contact? 
Best time to call: 


Driver Information
Driver 1
Name: 
D.O.B.:  (MM/DD/YYYY)
Marital Status:  Married    Single
Gender:  M      F
Good student?  Yes    No
Driver Training?  Yes    No
Occupation: 
Driver 2
Name: 
D.O.B.:  (MM/DD/YYYY)
Marital Status:  Married    Single
Gender:  M      F
Good student?  Yes    No
Driver Training?  Yes    No
Occupation: 

Driver 3
Name: 
D.O.B.:  (MM/DD/YYYY)
Marital Status:  Married    Single
Gender:  M      F
Good student?  Yes    No
Driver Training?  Yes    No
Occupation: 


Automotive Information
Auto 1
Year: 
Make:  (Ford, Chevy, etc.)
Model:  (Taurus, Blazer, etc.)
Vin #:  (17 Digit Car ID)
Primary Use: 
Commute:  (Miles one way)
Principle Operator:  Driver  1    2    3
Existing Damage:  Yes    No

Auto 2
Year: 
Make:  (Ford, Chevy, etc.)
Model:  (Taurus, Blazer, etc.)
Vin #:  (17 Digit Car ID)
Primary Use: 
Commute:  (Miles one way)
Principle Operator:  Driver  1    2    3
Existing Damage:  Yes    No

Auto 3
Year: 
Make:  (Ford, Chevy, etc.)
Model:  (Taurus, Blazer, etc.)
Vin #:  (17 Digit Car ID)
Primary Use: 
Commute:  (Miles one way)
Principle Operator:  Driver  1    2    3
Existing Damage:  Yes    No


Requested Amount of Coverage
Liability: 
Medical Payments: 
Comprehensive Deductible: 
Property Damage: 
Uninsured and Underinsured Motorist: 
Collision Deductible: 
Rental Reimbursement: 
Towing: 


General Information
1. All vehicles registered to applicant?  Yes    No
2. Any vehicles with modifications or special equipment?  Yes    No
3. Any other auto insurance in household?  Yes    No
4. Any household resident not listed as operator?  Yes    No
5. Any drivers with physical or mental impairments?  Yes    No
6. Any driver's license been suspended or revoked?  Yes    No
7. Any insurance declined, cancelled or non-renewed past 3 years?  Yes    No
8. Car at school?  Yes    No

List date and type of accidents/convictions last 3 years (all drivers):
Date  Type 
(MM/DD/YYYY)     
(MM/DD/YYYY)     
(MM/DD/YYYY)     

Prior Insurance Company: 
Current Expiration Date:  (MM/DD/YYYY)

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