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DO YOU HAVE THE RIGHT PROTECTION
OR
DEADLY COVERAGE GAPS?

Complete the form below and we'll show you great rates for comparable coverage.  Then, if you're interested, we'll take the time to review your coverage, and point out any deadly gaps you may have.

Personal Information

Full Name:
Mailing Address:
Home Address (if different):
Daytime Phone Number: (+ area code)
Evening Phone Number: (+ area code)

Driver Information

Date of Birth
Gender
Status
Tickets/Accidents
1.
2.
3.
4.
Provide details below if in the last three years any driver has been convicted of traffic violations or involved in an accident, or in any other types of claims have been made (theft, vandalism, hail, etc.).

Vehicle Information

Year Vehicle Make Vehicle Model No. of Doors
Car 1

Car 2

Car 3

Car 4

V.I.N.
Serial Number
Anti
Theft
Air
Bags
ABS
How is the
Vehicle Used?

Annual Mileage
under 7500 miles?

Car 1

Car 2

Car 3

Car 4

Liability Limits

 COVERAGE

VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4
Bodily
Injury

Each
Person

Each
Accident

Each
Person

Each
Accident

Each
Person

Each
Accident

Each
Person

Each
Accident

Property
Damage

Each
Accident

Each
Accident

Each
Accident

Each
Accident

Medical
Payments

Uninsured and
Underinsured
Motorist

Each
Person

Each
Accident

Each
Person

Each
Accident

Each
Person

Each
Accident

Each
Person

Each
Accident

Comprehensive
Deductible
Rental
Reimbursement
Collision
Deductible
Leases/Loan
Coverage
Do you currently have auto insurance?  If yes, please give the name of your company.
How did you find us?

You are on your way to Auto Insurance savings with Cairnes-Tapley Insurance.  Thank you for your time.  Leave comments below and don't forget to click the "send" button.

Comments 

This is not a binding contract of insurance.
The above information obtained is for the purpose of a
Quick Quote
and is subject to accuracy of information provided.