Auto Fact Finder

Please complete the form below most of this information you can find on your current Declarations Page or you can call Robert at 203-510-5430 to take information over the phone.

Section 1 Basic Information

Best Phone Number To Reach You Regarding Quote

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How Many Licensed Drivers In you Household

Name

First Name

Last Name

Name of Second Driver

Please Provide info if more then 1 Driver in Household.

First Name

Last Name

Name of Third Licensed Driver

First Name

Last Name

Name of Fourth Licensed Driver

First Name

Last Name

If more then 4 Drivers Please Provide Full names of Additional Drivers

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Section 2 Vehicle and Driver Information

Year / Make/ Model Vehicle 1

Vin Number Vehicle 1

Principal Driver Vehicle 1

First Name

Last Name

Date Of Birth Driver of Vehicle 1

YYYY

CT Drivers License Number Driver 1

Vehicle Usage for Vehicle 1

Year/ Make/ Model Vehicle 2

Vin Number Vehicle 2

Principal Driver Vehicle 2

First Name

Last Name

Date of Birth Driver of Vehicle 2

YYYY

Drivers License Number Driver of Vehicle 2

Vehicle Usage Vehicle 2

Year/ Make/ Model Vehicle 3

Vin Number Vehicle 3

Principal Driver Vehicle 3

First Name

Last Name

Date Of Birth Driver of Vehicle 3

YYYY

CT Drivers License for Driver of Vehicle 3

Usage

If more then 3 Licensed Drivers or Vehicles Please List the Other Vehicles Year/ Make/ Model/ Vin Number

If More then 3 Drivers Please List Additional Drivers Names/ Date of Birth/ CT Driver License Number/ and Usage of the Vehicle

Current Coverage Information

We try to provide quotes "Apples to Apples" so we match your current coverage with other companies at the same limit levels and sometimes make suggestions and help you understand what these limits mean.

Bodily Injury Liability Limit

Property Damage Liability Limit

Uninsured Motorist Limit

Collision Deductible

Comprehensive Deductible

Do you Currently Have towing and or Rental Car Coverage

Towing

Rental Car Coverage

Medical Payment Limit

Current Coverage Expiration Date

YYYY

Current Coverage Company

Tickets /Accidents/ Major Incidents Last 5 Years

If Tickets or Accidents Explain and Provide a ballpark date

Any Other Claims last 3 years?

Any Discounts? (Good Student, Driver Training, Student Away at school w/o car, AAA...etc...) If So list below