Tucson Insurance Agency


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Complete the following information and we will contact you with a quote.

Name:
Your Date of Birth:
Spouse Name:
Spouse Date of Birth
Street Address:
City:
Zip:
Phone:
Email:
Additional Drivers  
Name:
Date of Birth:
Good Student: Yes No
Accidents/Citation: Yes No
Name:
Date of Birth:
Good Student: Yes No
Accidents/Citation: Yes No
Name:
Date of Birth:
Good Student: Yes No
Accidents/Citation: Yes No

Have YOU had an accident in the last 3 years? Yes No
How Many?
What happened?
Have YOU had a citation in the last 3 years? Yes No
How Many?
What was it for?
What insurance company are you currently with?
Policy Number?
How long have you been with them?
When does the policy expire?
Liability Limits:
  Car 1 Car 2 Car 3 Car 4
Year
Make
Model
4dr/2dr
4x4 Yes
No
Yes No Yes No Yes No
# Airbags

Anti-Lock
Brakes

Any Business
Use?
Yes
No
Yes No Yes No Yes No
Miles Per Year
COVERAGE
Bodily Injury
Property Damage
UIM
UM
Medical Payments
Comp. Deductible
Collision Deductible
Glass Yes
No
Yes
No
Yes
No
Yes
No
Towing Yes
No
Yes
No
Yes
No
Yes
No
Rental Yes
No
Yes
No
Yes
No
Yes
No
VIN
Current Premium

 

 

 


 

 

 

Shestko-Montiel Insurance Agency
648 N. Stone Ave
Tucson, AZ 85705
Phone: 520-624-3309
Fax: 520-624-7064
Email: lshestkomontiel@allstate.com