Safe & Sound Insurance, Inc.
On-Line Quote Form
(503) 460-3333

Gary@Safe-n-Sound-Insurance.com

Please complete our 4-part form below. You may also print it and send it by fax to (503) 335-5898.
We will send you a quote by E-MAIL within one business day.
You MUST be an OREGON resident.

(1) PERSONAL INFORMATION

Name:
Address:
City:
State: Zip:
Telephone:
E-Mail:
Previous Insurance: Yes
No
Company:
How Long?
Oregon License: Yes
No
If NO, what state?
How long licensed?
How long in Oregon?

(2) VEHICLES


1. Yr/Make: Model: Coverage:
2. Yr/Make: Model: Coverage:
3. Yr/Make: Model: Coverage:
4. Yr/Make: Model: Coverage:

(3) DRIVERS

DRIVER 1:
Birthdate:
Occupation:
Gender:
Marital Status:

If Contractor, Framer, Painter, or any type of construction worker, how many job sites does this driver visit per day?
DRIVER 2:
Birthdate:
Occupation:
Gender:
Marital Status:

If Contractor, Framer, Painter, or any type of construction worker, how many job sites does this driver visit per day?
DRIVER 3:
Birthdate:
Occupation:
Gender:
Marital Status:

If Contractor, Framer, Painter, or any type of construction worker, how many job sites does this driver visit per day?
If you are married and your spouse does not drive, then please fill out the following information:
Name of Spouse:
Birthdate:
License Status: Never Licensed
Suspended License
Not Licensed Any Longer
If no longer licensed, why?

(4) DRIVING RECORD


Please indicate type of TICKET and approximate date:





Please indicate all ACCIDENTS below, including approximate date and fault. If you were not at fault, is there proof? (A State Accident Report is not sufficient proof.): List 3 Most Recent Accidents:

Date:Fault:
Date:Fault:
Date:Fault:
Comments:

Now click "SUBMIT" to send your information to Safe & Sound:


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Safe & Sound Insurance, Inc.
http://www.safe-n-sound-insurance.com