Primary Contact

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address *

State *

City *

Postal Code *

Vehicle 1

VIN (Vehicle Identification Number)

If No VIN: Year of Vehicle

If No VIN: Make of Vehicle

If No VIN: Model of Vehicle

Vehicle Ownership *

Length of Ownership *

Primary Use *

If Commute

Days Per Week
One-way Commute Mileage

Estimated Annual Mileage *

Vehicle 1 desired coverage (Full coverage/Liability only)

Vehicle 1 used for rideshare or delivery? (Yes/No)

Vehicle 1 lienholder name

Would you like to add another vehicle?

Vehicle 2

VIN (Vehicle Identification Number)

If No VIN: Year of Vehicle

If No VIN: Make of Vehicle

If No VIN: Model of Vehicle

Vehicle Ownership *

Length of Ownership *

Primary Use *

If Commute

Days Per Week
One-way Commute Mileage

Estimated Annual Mileage *

Vehicle 2 desired coverage (Full coverage/Liability only)

Vehicle 2 used for rideshare or delivery? (Yes/No)

Vehicle 2 lienholder name

Would you like to add another vehicle? (Vehicle 3)

Vehicle 3

VIN (Vehicle Identification Number)

If No VIN: Year of Vehicle

If No VIN: Make of Vehicle

If No VIN: Model of Vehicle

Vehicle Ownership *

Length of Ownership *

Primary Use *

If Commute

Days Per Week
One-way Commute Mileage

Estimated Annual Mileage *

Vehicle 3 desired coverage (Full coverage/Liability only)

Vehicle 3 used for rideshare or delivery? (Yes/No)

Vehicle 3 lienholder name

Primary Insured - Driver 1?
Add all drivers that will be covered on this policy.

Driver 1 *

First Name
Last Name
Gender
Date of Birth
Phone Number
Email
Marital Status
Education Level
Active Drivers License?
Employment Status
Employment: Industry
Employment: Occupation
Employed within the last 12 months?
Government/Military Affiliations
Military Affiliation
Military Branch
Military Grade
Military: Active or Retired
Government Grade
Student Type
Full-time student with a B average in the most recent semester?
Completed voluntary defensive driver course in last 3 years?

Driver 1 Date of Birth *

Drivers License Number *

Driver 1 license state

Age first Licensed?

Driver 1 relationship to primary insured (Self/Spouse/Child/Other)

Driver 1 license status (Valid/Suspended/Permit/Foreign/None)

Would you like to add another driver?

Driver 2

Driver 2 *

First Name
Last Name
Gender
Date of Birth
Phone Number
Email
Marital Status
Education Level
Active Drivers License?
Employment Status
Employment: Industry
Employment: Occupation
Employed within the last 12 months?
Government/Military Affiliations
Military Affiliation
Military Branch
Military Grade
Military: Active or Retired
Government Grade
Student Type
Full-time student with a B average in the most recent semester?
Completed voluntary defensive driver course in last 3 years?

Driver 2 Date of Birth *

Drivers License Number *

Age first Licensed?

Driver 2 relationship to primary insured (Self/Spouse/Child/Other)

Driver 2 license status (Valid/Suspended/Permit/Foreign/None)

Driver 2 license state

Would you like to add another driver?

Driver 3

Driver 3 *

First Name
Last Name
Gender
Date of Birth
Phone Number
Email
Marital Status
Education Level
Active Drivers License?
Employment Status
Employment: Industry
Employment: Occupation
Employed within the last 12 months?
Government/Military Affiliations
Military Affiliation
Military Branch
Military Grade
Military: Active or Retired
Government Grade
Student Type
Full-time student with a B average in the most recent semester?
Completed voluntary defensive driver course in last 3 years?

Driver 3 Date of Birth *

Drivers License Number *

Age first Licensed?

Driver 3 relationship to primary insured (Self/Spouse/Child/Other)

Driver 3 license status (Valid/Suspended/Permit/Foreign/None)

Driver 3 license state

Would you like to add another driver?

Additional Information needed to provide quotes

Current Insurance Carrier *

Current premium *

How many years have you had coverage with this carrier? *

Do you own or rent? *

Years at Current Residence? *

Accidents, violations or claims in the past 5 years (date, driver, type, at fault Y/N, payout amount)

Premium term (Monthly/6 months/12 months)

Years continuously insured

Current policy expiration date (MM/DD/YYYY)

Roadside (Yes/No)

Rental (Yes/No)

PIP (Yes/No)

UM/UIM (Yes/No)

Collision deductible

Comprehensive deductible

Desired liability limits (BI/PD)

Upload current auto coverage policy

Upload Here *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Additional Notes: Provide notes that help with quoting.

Example: Does client want liability only or specific coverage type?

Enter Notes Here

Requestor

Name of Agent Requesting Quote *

Email of Agent Requesting Quote. Quotes will be sent to this email *

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I understand that Eric Blazej, doing business as Fortify360 Insurance Group, and the insurance companies he quotes with may obtain and use credit-based insurance scores or credit information about me to rate and underwrite my policy, as permitted by Texas law. Each insurance company will give me its own credit disclosure notice, which explains how my information is used and my rights.

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Email: eric@fortify360insurance.com