License: #0735703
(619) 444 4664
[email protected]

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First Name

Last Name

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Please Tell Us About The Vehicle You Drive

Vehicle 1:

Year

Make (Ex: Mercedes-Benz):

Model (Ex: E320 CDI):

Style or Body Type (Ex:Sedan 4 Doors):

VIN # (Optional):

Yearly Mileage:

Primary Usage:

Commute To/From Work

Commute To/From School

Business Corporate

Farm

Pleasure

Business Individual

Government

Any Other

Any Custom Equipment On Vehicles?(if YES, give their value & indicate which vehicle):

Where Is The Car Parked Overnight?:

No Cover

Garage

Carport

Vehicle 2:

Year

Make (Ex: Mercedes-Benz):

Model (Ex: E320 CDI):

Style or Body Type (Ex:Sedan 4 Doors):

VIN # (Optional):

Yearly Mileage:

Primary Usage:

Commute To/From Work

Commute To/From School

Business Corporate

Farm

Pleasure

Business Individual

Government

Any Other

Any Custom Equipment On Vehicles?(if YES, give their value & indicate which vehicle):

Where Is The Car Parked Overnight?:

No Cover

Garage

Carport

Current Insurance Information (if applicable)

Insurance Company Name:

Policy Expiry Date(MM/DD/YYYY):

Term (Months):

Same Company Policy Since? (YYYY):

Premium Amount Per Month ($):

Driver’s Information

Driver 1:

Full Name:

Sex:

Male

Female

DL # (Optional):

Date Of Birth (MM/DD/YYYY):

Marital Status:

Single

Married

Education:

Occupation:

Driver 2:

Full Name:

Sex:

Male

Female

DL # (Optional):

Date Of Birth (MM/DD/YYYY):

Marital Status:

Single

Married

Education:

Occupation:

Accidents / Violations In Last 5 Years

Minor Violations – Speeding, Turn, Stop Sign, Red Light, etc

(Driver 1)

(Driver 2)

Accidents – Non Chargeable: (Driver 1)

(Driver 2)

Chargeable Accident Cost ($):

(Driver 1)

(Driver 2)

Major Violations – Drunk driving, Reckless, Hit And Run, etc.:

(Driver 1)

(Driver 2)

Any additional comments or information that might be helpful in your quote:

Disclaimer

No coverage of any kind is bound or implied by submitting information via this online form.

We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

Yes I agree

At Jenkins Financial Insurance Agency, we work on humanitarian principles. To us, that means being there, emotionally and financially, for a customer who has suffered a loss. And it means responding to the needs of the community when disaster strikes, with money and volunteers.

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Jenkins Financial Insurance Agency 236 Jamacha Road Suite 102 El Cajon, CA 92019-2366
(619) 444 4664
[email protected]

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