Full Name of Driver:
Mailing Address of Driver: (Same OK for subsequent Drivers)
Street Address:
Name of City:
County of RESIDENCE:
Enter Zip Code:

Currently only TEXAS quotes are being Processed:
Enter E-Mail Address to Receive Quote:
Phone Number (Day phone)
Sex of Driver: Male Female
Married? Yes No
Date of Birth of Operator (mm/dd/yy)
Do You have a Major Credit Card? Yes No
Do You own your own home? Yes No
Is it a mobile home? Yes No
What is Your Occupation

Have you carried AUTO INSURANCE for the last 6 months with no more than a 7 - 30 day lapse?
Have NOT CARRIED Insurance Have Carried Coverage WITHOUT LAPSE. Less than 7 Day Total Lapse >More than 7 less than 30 day lapse

Do You have a Current DEFENSIVE DRIVING CERTIFICATE (anyone) or a DRIVERS TRAINING CERTIFICATE (Males under 25, or Females under 21)? Have DDC or Drivers Training DON'T Have DDC or Drivers Education

Do You Have Any Tickets or Accidents (Chargeable-Your Company Paid)?
Select All That Apply:
  None
  Accidents
  Speeding
  Ran Stop Sign/Light
  Other Violation (Explain below)

PLEASE GIVE CIRCUMSTANCES OF ANY ACCIDENTS.
If "Other" Was Checked AND/OR if you have more than 1 incident of a violation, or If you indicated a violation above, please give dates & explain: 

Vehicle Number 1

Year Model of FIRST Auto: 2000 1999 1998 1997 1996 1995
1994 1993 1992 1991 1990 1989 1988 Prior to 1987

Does your vehicle have AIR BAGS or AUTOMATIC SEATBELTS? NO Airbags or Automatic Seat Belts Drivers Side ONLY Both Sides Have Airbags or Automatic Seat Belts

Does your vehicle have a FACTORY INSTALLED ALARM SYSTEM?
If not factory installed, explain in remarks below!
Do HAVE a Factory Installed Alarm DO NOT Have a Factory Alarm Have NON-FACTORY (explain below)

Select Comprehensive (OTC) Deductible:
No Coverage Desired $100 $200 $250 $500 $1000

Do You wish to ADD TOWING & LABOR (Available only with Comprehensive & Collision) Add It! NO, I'll WALK

FINALLY, Do you want RENTAL REIMBURSEMENT (Applies only to a COVERED LOSS that disables your auto):
Add It! NOPE

Vehicle Number 2

Type of Automobile: (List name, model, body type) (ie Ford Tempo G/L 2Door)of Vehicle #2

YEAR MODEL OF SECOND AUTO: 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 Prior to 1987

Does your vehicle have AIR BAGS or AUTOMATIC SEATBELTS? NO Airbags or Automatic Seat Belts Drivers Side ONLY Both Sides Have Airbags or Automatic Seat Belts

Does your vehicle have a FACTORY INSTALLED ALARM SYSTEM?
If not factory installed, explain in remarks below!
Do HAVE a Factory Installed Alarm DO NOT Have a Factory Alarm Have NON-FACTORY (explain below)

Select Comprehensive (OTC) Deductible: 
No Coverage Desired $100 $200 $250 $500 $1000

Do You wish to ADD TOWING & LABOR (Available only with Comprehensive & Collision) Add It! NO, I'll WALK

FINALLY, Do you want RENTAL REIMBURSEMENT (Applies only to a COVERED LOSS that disables your auto):
Add It! NOPE

List Additional Autos in Remarks Section Below. If Comprehensive & Collision is desired, be sure to specify.

REMARKS:

Limits of Liability & Deductibles

In this Section, Please select Limits of Liability & Deductibles Select Limit of Liability Insurance Desired (format is 20,000 per person bodily injury liability, subject to a maximum of $40,000 per occurrence and $15,000 for property damage liability. Will be shown as $20,000/40,000/15,000)Combined Single Limits may be substituted for split limits. See you return form for exact quotation:

Limit of Uninsured Motorist Coverage Required (May be Rejected, form must be signed)
REJECT IT! $20,000/40,000/15,000 $25,000/50,000/25,000 $50,000/100,000/50,000 $100,000/300,000/100,000

Personal Injury Protection (Medical Payments, Lost Wages, Lost of Domestic Services) This Coverage Must Be accepted or REJECTED IN WRITING (Form Signed)  
$2500 $5000 $7500 REJECT!

At this point, send this form to Bill Taylor & Associates for Quote. You will be given an opportunity to enter Additional Drivers (MANDATORY IF MARRIED & LIVING WITH SPOUSE). Be sure to show all residents of your household that are 14 or over. Some companies allow exclusion of youthful operators or roommates. Please comment under remarks if this is desired.