HemphillInsuranceAgency.com

We've Made Shopping For Any Kind Of Insurance Coverage Fast, Easy, and Available Online

    

                         Home  | About Us | Contact Us | Applications & Forms

 

Compare Auto Insurance Coverage & Rates Before You Buy

To Get A Quick Quote With Several Leading Insurance Companines Just Complete A Short Online Information Form

Safeco Insurance
 
 

Automobile Insurance Quote Request

       

 

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Auto Quote Request Form - (Texas Residents Only!)

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

First Named Insured:

Additional Named Insured ( Usually Spouse):

 

*Full Name (as shown on your drivers license):

Full Name (as shown on your drivers license)

*SSN #

*DOB:

SSN #

DOB:

           (ie;999-99-9999)

         (MM/DD/YYYY)

       (ie;999-99-9999)

         (MM/DD/YYYY)

*Business/Industry : *Occupation

If "Other" Occupation Please Describe

*Highest Level of Education

 

 

Business/Industry : Occupation

If "Other" Occupation Please Describe

Highest Level of Education

Email Address:                                                            (For Our  Agency Staff Use Only)

*Email Address :                (For Our  Agency Staff Use Only )

 

Fax #

 

*Send Quick Quote By : Email Fax Both

 

*Contact Phone Numbers:

        Day :   

 

Evening :   

 

        Cell : 

 

Do you currently have auto insurance?    Need help with this question call 1-800-361-8734 !
If currently insured, how long have you had insurance without a gap in coverage?

If no, how long has it been since you had car insurance?

At what age did you become a licensed driver?

If yes, Name of Current Carrier:  

Policy #  

Expiration Date:

 

Location Your Automobiles Are Garaged At : 

City: State:

 

Physical Address:        

 *Address:  

*City:

 *State: Zip:

*County :

Mailing Address:       Same as Mailing Address
 Address:
 

City:

State:   Zip: 

County : 

Driver Information:

Please list all family members of your household who are licensed drivers;even if you do not wish to cover them for use of your vehicles..

 Driver  Number

 Name / Employment

 Gender / Marital Status

 Driver License / State / Date Of Birth  Relationship

 History :  Any reportable Accidents/Major Violations/Comp Claims within the past 5 years or minor violations within past 3 years?Need help with these questions call 1-800-361-8734 !

Driver 1

Full Name


Driver's License #

State

DOB

Relationship to Primary Insured:

At Fault Accidents/Major Violations 

Not At Fault Accidents/Comp Claim

Minor Moving Violations/Tickets     

Driver 2

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At Fault Accidents/Major Violations 

Not At Fault Accidents/Comp Claim

Minor Moving Violations/Tickets     

Driver 3

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At Fault Accidents/Major Violations 

Not At Fault Accidents/Comp Claim

Minor Moving Violations/Tickets     

Driver 4

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At Fault Accidents/Major Violations 

Not At Fault Accidents/Comp Claim

Minor Moving Violations/Tickets     

Driver 5

Full Name

Driver's License #

State

DOB

Relationship to Primary Insured:

At Fault Accidents/Major Violations 

Not At Fault Accidents/Comp Claim

Minor Moving Violations/Tickets     

* Do You Want Us To Also Provide You With A Separate Quote For A Personal Umbrella Liability Policy ? Yes

Vehicle Information:

    Car Number

Year

Make

Model /  Date Purchased / Cost

Vehicle ID NumberNeed help with this locating your Vehicle Identifcation Number (VIN) call 1-800-361-8734 !

Driver#

Usage / Miles / AV Daily Miles

Car 1

Model 

Date Purchased                     

Cost New    

Average Miles Per day

Car 2

  

Model 

Date Purchased                     

Cost New    

 

Average Miles Per day

Car 3

  

Model 

Date Purchased                     

Cost New    

 

Average Miles Per day

Car 4

   

Model 

Date Purchased                     

Cost New     

 

Average Miles Per day

Car 5

 

 

 

 

 Model 

Date Purchased                     

Cost New    

 

 

 

 

 

 

 

 

 

 

 

Average Miles Per day

 

 

Coverage Limits:

 

BI/PDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

UMBI/PDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

PIP/MEDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

COMP Ded

COLL Ded

Towing

 Rental Car

Car 1

Car 2

 same as car 1

same as car 1

same as car 1

Car 3

 same as car 1

same as car 1

same as car 1

Car 4

 same as car 1

same as car 1

same as car 1

Car 5

 same as car 1

same as car 1

same as car 1

Additional Underwriting Information :Need help with these questions call 1-800-361-8734 !

Pre-selected (Default ) answers have been selected by us to aid you in completion of this form;  please make any necessary corrections. Please review each check box below to assure that each question is correctly answered; then change the checked box to the most appropriately response that applies to your request for a rate quote. Any incorrect information obtained from you may void the quick quote rate you receive.

Rate Discounts (available only with written proof of course completion) :

    Driver Training Course      

     Accident Prevention Course

     Alcohol/Drug Awareness Course

 

Has any driver living in your household (even if not a listed on driver information above) had their driver's license suspended or revoked in the last 5 years? Yes No

Brief Details

Has any insurance company cancelled, declined or refused renewal any driver in your household (even if not a listed on driver information above) during the past 5 years? Yes No

Brief Details

Driver Training

  Date Competed

 Accident Prevention

  Date Competed

 AD Awareness Course

Date Competed

If anyone to be insured received a ticket or fine for a major violation in past 5 years (as reported in history above ) please provide :  

Type Violation Date   

Brief Details

Reason you are shopping for new auto policy  Date Last Accident Reported ( if applicable)
Do you want this quoted for an annual term if available? (Please note: Choosing a 12 month term could result in a higher premium quoted.)      Yes No Do You Need To File A SR-22 Filing ? Yes No  

(This is usually a court ordered financial responsibility requirement for drivers who are required by a court at law to provide the court with ongoing poof of auto insurance )

Does Someone Else Own Any Vehicle Listed Above? Yes No If "Yes" Provide Brief Details: Are all household members listed as drivers? Yes No

If "No" Please list all household members not listed as  drivers  (e.g., Name, Date of Birth, Relationship to Insured & Briefly Explain Circumstances Involved):

Are all vehicles garaged at mailing address ? Yes No Are all household members US Citizens?  Yes No             

If "No" Name Drivers   

Number of Fire/Theft/Comp Claims within last 3 years?                 

If any claims please explain below

Corporate Owned Vehicle? Yes No                                       

If "Yes" please explain below

Comments/Remarks:

 

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. 

 To confirm binding or current policy revisions you must receive a written confirmation for any  new or change in coverage from our agency staff.

    

       

 

Click Here To View Glossary of Auto Insurance Terms

Auto insurance pays for damages, injuries, and other losses that are detailed in your policy. Depending on the type of coverage, auto insurance can either pay for your damages or another driver’s damages, or a passengers damages.

The most common types of auto insurance are:

LIABILITY pays for damage caused by you to another person or another person's vehicle or other property as a result of an automobile accident. Types of liability coverage include:

 

bulletBodily Injury (BI) If you injure someone in an auto accident for which you are legally to blame, this coverage will pay claims for injury or death against you and the cost of legal defense.

Please keep in mind that you are responsible for any amount of a covered loss that exceeds the amount of insurance coverage you purchase; therefore we highly recommend you consider securing higher limits of bodily insured auto liability coverage to protect your personal assets in the event of a large liability settlement or a count renders a judgment for a dollar amount that exceeds your policy limits. We would highly recommend you request a quote for a Personal Umbrella Liability Policy as recent court judgments to claimants for wrongful death , pain & suffering due to injuries , medical expenses , and/or loss of income due to a negligence of another party have been substantial.

 

bullet Property damage (PD) pays for damage that you cause to someone else's vehicle or property for which you are legally liable. This does not cover your car or property.

Please keep in mind that you are responsible for any amount of a covered loss that exceeds the amount of insurance coverage you purchase; therefore we highly recommend you consider securing higher limits of property coverage to protect your personal assets in the event of a large liability settlement or a court renders a judgment for a dollar amount that exceeds your auto property damage policy limits due damages you cause to someone else's property. Accidents involving multiple automobiles, high valued automobiles, or commerical vehicles may result in substantial losses that exceed coverage limits available under a standard Texas auto policy so we would highly recommend you request a quote for a personal Umbrella Liability Coverage.

 

bullet Medical payments pays for medical, hospital or funeral expenses for you and others injured or killed while riding in your car, regardless of fault. It also covers you and family members if struck by a car as a pedestrian or if riding in another car.

PHYSICAL DAMAGE pays for a loss resulting from damage to your vehicle or a vehicle operated by you. Physical damage also provides coverage if your vehicle is stolen. Types of physical damage coverage include:

 

bullet Collision pays for damage to your car from an accident regardless of fault. It usually includes a deductible and the insurance company pays the rest. Selecting a larger deductible can lower your collision premium.

 

bulletOther Than Collision (Comprehensive) pays for damage to your car caused by most anything other than a collision. Glass breakage, theft, fire, explosion, impact with an animal, vandalism and flood are some of these hazards. This coverage is also available with deductibles to lower your premium.

OTHER COVERAGE Other types of auto coverage include:

 

bullet Uninsured Motorists (UM) Unfortunately, not everyone purchases auto insurance. If you or your passengers are injured by someone who does not carry auto insurance, UM coverage will pay for injuries up to your policy limits. This includes medical expenses, loss of wages, and related expenses. UM coverage also applies if you are a victim of a hit-and-run driver.

 

bullet Underinsured Motorists (UIM) Just as some drivers don't carry any auto insurance, other's don't carry enough to pay for damages from their accidents. UIM coverage pays for death and injury expenses to you or occupants of your car when the other person's insurance is inadequate.

 

bullet Personal Injury Protection (PIP)) Coverage pays for medical expenses and 80% of lost income, regardless of who is at fault in the accident. It also pays for assistance with personal services you are unable to perform because of an auto accident. You, your family members, and your injured passengers are covered under PIP. Insurance; insurance companies must offer to sell you PIP coverage (and Uninsured Motorist Coverage) along with your liability coverage. If you decide not to purchase PIP, you must reject it in writing. PIP coverage is available at limits of $2500 and up.

 

bullet

 

Rental Reimbursement pays for the cost to rent an automobile up to the daily and total maximum amount of coverage you purchase ;up to your available policy limits;  while your vehicle is being repaired or replaced should a total loss occur from damage or theft.

 

bullet

 

Towing pays for the cost have your vehicle towed to a repair shop ; up to your per select policy limit; by a wrecker service should you automobile be damaged under your policy for a covered loss.

2007 Automobile Underwriting Guidelines

What is an underwriting guideline?

An “underwriting guideline" is a rule, standard, guideline, or practice, whether written, oral, or electronic, that is used by an insurance company (or its agent) to decide whether to accept or reject an application for a personal automobile insurance policy or to determine what rate will apply to an applicant once the application is accepted.

To view the 2007 Automobile Insurance Underwriting Guidelines in PDF format please CLICK HERE
 
In order to the PDF you will need the free version of Adobe Acrobat.

Texas Automobile Insurance Underwriting Guideline Comparison For 1994-1996-1999

Results In the Standard Rate Regulated Market
 Percentage Of Carriers Who Applied These Underwriting Guidelines In The Standard Auto Insurance Market In The Following Years : 1994 1996 1999
Canceled by another company. Applicants are asked whether or not their insurance was canceled by another insurer. During the time period covered by the guidelines reviewed for 1996, a new rule made it illegal to base underwriting decisions on this information although it was still legal to ask an applicant. It is unknown how this information was used. The rule prohibiting use of this guideline has been overturned by the Texas Supreme Ct. 71% 65% 60%
No prior insurance. Insurer will not offer coverage to an applicant who is not currently insured or has not maintained continuous coverage for a specified period. Rules prohibit use of this guideline if applicant was uninsured for 30 days or less during the last year. 71% 46% 83%
Age. Applicants are denied based on their age, even though the rates set by the state allow for rating classification by age. Generally, these guidelines refuse coverage to young drivers, with some exceptions for those who are covered on their parents policy, and to older drivers. 91% 93% 84%
Occupation. Applicants are denied because of their occupation. Some guidelines allow certain occupations or professions to have more blemishes on their driving/claim record. 56% 65% 56%
Residential stability. Applicants are denied if they have not lived at the same address for a specified period of time, usually 2-3 years, or is a homeowner. 67% 85% 77%
Employment stability. Applicants are denied if they have not worked for the same employer for a specified period of time, usually 2-3 years. 51% 47% 64%
Not-at-fault accidents and claims. Applicants are denied because they have made a claim for, or been involved in, an accident or accidents in which the applicant was not at fault. 52% 21% 61%
Foreign Nationals. Applicants are denied because they do not meet the insurers residency requirements and/or requirements that the applicant have driving experience in the United States for a required period of time, usually several years. 58% 44% 64%
Marital Status. Insurer considers the applicants marital status. Many of the guidelines ask for specific information such as widowed, divorced, separated, although the rating manual only distinguishes between married or not married for certain young driver categories. 48% 45% 61%
Other coverage. Applicants are denied the minimum liability coverage required by law unless they agree to buy other coverage. While legal for the 1994 report, this guideline was illegal during the period covered by the 1996 guidelines. The department of insurance rules prohibiting its use is still in effect. 38% 22% 54%
Previous insurer nonstandard. Insurer refuses to sell to those who have been insured in the nonstandard market (county mutual or assigned risk plan). While legal for the 1994 report, this guideline was illegal during the period covered by the 1996 guidelines. The rule prohibiting use of this guideline has been overturned by the Texas Supreme Court. 15% 44% 64%
Credit history. Applicants are denied coverage because of their credit history. Insurers often use "risk scores" which combine credit information with demographic data. 25% 58% 66%
Driving experience. Applicants are denied if they do not have at least 3 years of driving experience. The number of years of experience required varies by insurer up to a maximum of 14 years. 43% 25% 71%

 

We Offer Non-Standard Auto Risk Coverage From Several Insurance Companies That Specialize In Insuring Drivers Who Do Not Meet Typical Standard Market Underwriting Guidelines - As Shown Above. 

We will normally provide Non-Standard Auto Risk Coverage quotes within 24 hours of a quote request.