Server: Microsoft-IIS/3.0 Date: Thu, 18 Dec 1997 10:53:38 GMT Content-Type: text/html Accept-Ranges: bytes Last-Modified: Thu, 11 Sep 1997 22:22:40 GMT Content-Length: 84508 20th Century Industries - Request for Rate Quotation
REQUEST FOR RATE QUOTATION
This quotation request form is for new clients only. If you are a current 20th Century policy holder, please call 1-800-443-3100 (in California) or 1-800-874-0222 (in Arizona) so we may service you better. 
IMPORTANT - PLEASE BE SURE TO ANSWER EVERY QUESTION

PERSONAL INFORMATION

Name: First Middle Initial Last 
Residence/Garaging Address: Number Street Unit  
City State Zip 
Telephone Number: Home Business 
Mailing Address (if different from residence address shown above)
Number Street Unit  
City State Zip 
 
Present Auto Liability Insurance Company 
How Long Insured?
years months 
Expiration Date (Mo/Day/Yr) 
Total number of Years of Continuous Liability Insurance 
(Include Years Insured with ALL Companies ) years months 
 
VEHICLE INFORMATION (INCLUDING TRAILERS AND MOTORHOMES)
PLEASE BE SPECIFIC ON MODEL & SUB-MODEL

VEHICLE NUMBER
1.
2.
3.
4.
Year
Make
(if other, specify:)
 
 
 
 
Model
(Taurus, Accord, etc.)
Sub-Model
(SE, LX, 4x4, etc.)
Body Style
Number of Doors
Number of Cylinders 
Turbo
Yes/No 
Yes No  Yes No  Yes No  Yes No 
LoJack*
Yes/No 
Yes No  Yes No  Yes No  Yes No 
Fuel
Used in Business Other Than to and From Work? 
Yes No  Yes No  Yes No  Yes No 
# of Days Per Week Driven to Work or School
One_Way Driving
Distance 
Total Annual
Mileage 
* LoJack theft recovery device is relevant for California drivers only

FOR TRUCKS -- PLEASE PROVIDE THE FOLLOWING ADDITIONAL INFORMATION
 
VEHICLE NUMBER
1.
2.
3.
4.
Tonnage
Drive Train 
Dual Wheels  Yes No  Yes No  Yes No  Yes No 
Cab Type (STD, Xtra, etc.): 
Camper  Yes No  Yes No  Yes No  Yes No 
If yes, price new:  $  $  $  $ 
Camper shell  Yes No  Yes No  Yes No  Yes No 

FOR TRAILERS OR MOTORHOMES -- PLEASE PROVIDE THE FOLLOWING ADDITIONAL INFORMATION
VEHICLE NUMBER
1.
2.
3.
4.
Retail Cost New (Less tax & license)  $  $  $  $ 
Length  (ft.)  (ft.)  (ft.)  (ft.) 

DRIVER INFORMATION
PLEASE LIST ALL LICENSED DRIVERS IN THE HOUSEHOLD (RELATIVES, ROOMMATES, ETC.)
Drivers 
1.
2.
3.
4.
5.
First name:
Middle initial:
Last name: 
Self








Relationship 
Self
Birthdate
Month/Day/Year 
Sex
MF
M F  M F  M F  M F   
Marital
Status 
Driver is Principal
User of Vehicle #
Number of 
Accidents**
Last 5 Years
Number of Traffic
Convictions** 
Last 3 Years
Date first licensed
in U.S. or Canada Month/Year  
Date First 
licensed outside 
U.S. or Canada 
Month/Year 
Which Country 
 
 
 
 
 
 
**Please explain any Accidents or Traffic Convictions in the section below

PLEASE DESCRIBE ANY ACCIDENTS (REGARDLESS OF FAULT) OR TRAFFIC CONVICTIONS INVOLVING YOU OR ANY DRIVER:

ACCIDENTS IN THE LAST FIVE YEARS
Driver's Name:  Accident Date [mo/yr]: 
Description: 
Amount of Damage $ 
Was anyone injured in the accident? Yes No 
Whose insurance co. paid the loss? Yours Other Driver's 
 
Driver's Name:  Accident Date [mo/yr]: 
Description: 
Amount of Damage $ 
Was anyone injured in the accident? Yes No 
Whose insurance co. paid the loss? Yours Other Driver's 

TRAFFIC CONVICTIONS IN LAST 3 YEARS
Driver's Name:  Date [mo/yr]:  
Description: 
 
Driver's Name:  Date [mo/yr]:  
Description: 
 
Driver's Name:  Date [mo/yr]:  
Description: 
 
Driver's Name:  Date [mo/yr]:  
Description: 

OCCUPATION
Driver #1 
Driver #2 
Driver #3 
Driver #4 
Driver #5 
*IF ENGINEER, SEE SECTION BELOW
FOR ENGINEERS ONLY
Supplementary Occupational Information 
Please indicate the field of engineering in which you are degreed or licensed. (If more than one driver is an engineer, pick any one). 

Does any driver own a vehicle NOT listed above? Yes No 
If yes, please state which driver:
Is vehicle presently insured?
Yes No 
 
How did you find our Web site?
(Please check appropriate box and fill in requested information. Thank you.)
Browsing 
Hyperlink (name original site)  
Friend told me of site 
Newspaper Ad/Flyer (3-digit ext. or reference code after "800" phone number)  
Direct Mail (6-digit source or reference code on bottom of personalized form starting with AD)  
Other