Reinard Insurance Agency

Please fill out this form completely to receive your quote:

Your Personal Data
Name (required):
Street Address:
City
State:
Zip Code:
E-mail Address (required):
Phone Number:
Fax Number:
Marital Status Single Married	Homeowner Yes No
Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)
Total number or collector vehicles owned:
List regular transportation in household:	Automobile:	Insurance Carrier:




To what automobile clubs do you belong?

DRIVER INFORMATION #1
Name:		Birthdate:
Sex (M/F):		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need a DL123 FILING?	Yes No	If YES to DL123 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an DL123 FILING?	Yes No	Comments or Remarks?

VEHICLE INFORMATION
Year of vehicle:		Make & Model:
		Vehicle Number:
Annual Mileage:		Condition? (1 to 100 - Perfect):
VEHICLE #1 COVERAGES:
Liability:	$100,000 $300,000 $500,000 $1,000,000
Agreed Value:	$
Previous losses or violations?		Yes No`(Explain below)`

Any operators under 25 years of age?		Yes No

Is vehicle used for rallying or racing?		Yes No

Is vehicle used for driving to or from work/school?		Yes No

Is vehicle used for errands, back-up, primary or secondary transportation?		Yes No

Does engine, body, or drivetrain differ from car maker's original?		Yes No `(Explain below)`

Will engine, body, or drivetrain be changed?		Yes No `(Explain below)`

Will horsepower or body be changed?		Yes No

How many licensed operators in household?

Describe garage construction (roof, walls, etc.):

Any security systems (fire, burglary, etc.):		Yes No `(Explain below)`

Additional Comments:

Comments or Remarks:
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Thank you for filling out this form COMPLETELY!

Photos of the vehicle are not required to submit this form, but WILL BE REQUIRED when the final application is submitted. Coverage cannot be bound without company underwriting approval.

In order to provide you with the BEST quote, we will need some additional information, such as your SS#. Please call us at 215-357-8600 to securely provide us with that information.

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me an Auto Quote

The Reinard Insurance Agency, Inc.
349 Bustleton Pike
Feasterville, PA 19053 (Directions)
Ph: 215-357-8600
Fx: 215-357-8061