WE RESPECT YOUR PRIVACY

Your privacy is important to us. Waguespack Insurance considers the protection of your personal information to be a primary goal. We respect your right to keep your personal information confidential.

We collect information in order to quote and service your insurance policy. This information is used only by our company and is not shared with any other vendor from which you could receive a solicitation.

Waguespack & Associates uses Secure Sockets Layer (SSL) protocol to interact with you when you provide personal information during the purchase and payment processes. We handle your information via 64-bit encryption. Every secure page has been secured with a digital certificate generated by COMODO Security. To view this certificate, click on the image of the "closed lock" or the "solid key" on the bottom of your browser window. A small frame displaying site security information will appear.

AS AN INDEPENDENT INSURANCE AGENCY...

we do not work for an insurance company; we work for you. We work on your side when you have a loss and follow through to see that you get a fair, prompt payment.

 

 
Auto Insurance Quote Form
To request a quote, please complete the form as completely as possible. If currently insured, your policy's declaration page will have much of the needed information. Type "unsure" in any required field in which you aren't sure of the answer. Your information will be forwarded to our agents, and all information is transferred securely and will be kept confidential.


Contact Information
Name
Street address
City
State
Zip Code
Daytime Phone
Evening Phone
FAX
E-mail Address

Insurance Policy Information

Are you currently insured?
CHECK ONE Yes        No*
*If No, please give reason not insured currently. i.e.: First time insured, policy canceled 3 mo's ago, etc.
If yes, by what company?
Policy expiration date?
Length of time continuously insured

 

Driver Information

Driver 1
Driver Name
Date
of Birth
Marital
Status
Gender
# Yrs Lic'd
# Tickets in
3.5 yrs*
# Accidents
in 3.5 yrs*
M
F

Commuting Miles
Driver 1 drives vehicle , miles to work or school
Occupation
Drivers License #
*Social Security#

Driver 2
Driver Name
Date
of Birth
Marital
Status
Gender
# Yrs Lic'd
# Tickets in
3.5 yrs*
# Accidents
in 3.5 yrs*
M
F

Commuting Miles
Driver 2 drives vehicle , miles to work or school
Occupation
Drivers License #
*Social Security#

Driver 3
Driver Name
Date
of Birth
Marital
Status
Gender
# Yrs Lic'd
# Tickets in
3.5 yrs*
# Accidents
in 3.5 yrs*
M
F

Commuting Miles
Driver 3 drives vehicle , miles to work or school
Occupation
Drivers License #
*Social Security#

Driver 4
Driver Name
Date
of Birth
Marital
Status
Gender
# Yrs Lic'd
# Tickets in
3.5 yrs*
# Accidents
in 3.5 yrs*
M
F

Commuting Miles
Driver 4 drives vehicle , miles to work or school
Occupation
Drivers License #
*Social Security#


* MUST GIVE DRIVERS LICENSE # IF ANY TICKETS OR ACCIDENTS
Give details of tickets or accidents below:

*Note regarding social security numbers: some companies now require your S.S.# to assess your financial responsibility and many of you may already be aware of this. If you are uncomfortable with this, leave it blank. You will be contacted by the agent if it's necessary. May not be necessary in all 50 states.


Vehicle Information
 

Vehicle 1
Year (1986)
Make  (Ford)
Model
(Taurus GL)
Body Type (Select all that apply):
2 Dr 4Dr Pickup Van
Wagon 4WD
Vehicle ID. #
Vehicle Leased? Yes No 
Comprehensive Deductible:
Collision Deductible:
Safety Features:
(Check all that apply)
1 Air Bag 2 Air bags Anti-Lock Brakes Passive Alarm
Daytime Run Lights Auto Seat Belts

Vehicle 2
Year (1986)
Make  (Ford)
Model
(Taurus GL)
Body Type (Select all that apply):
2 Dr 4Dr Pickup Van
Wagon 4WD
Vehicle ID. #
Vehicle Leased? Yes No 
Comprehensive Deductible:
Collision Deductible:
Safety Features:
(Check all that apply)
1 Air Bag 2 Air bags Anti-Lock Brakes Passive Alarm
Daytime Run Lights Auto Seat Belts

Vehicle 3
Year (1986)
Make  (Ford)
Model
(Taurus GL)
Body Type (Select all that apply):
2 Dr 4Dr Pickup Van
Wagon 4WD
Vehicle ID. #
Vehicle Leased? Yes No 
Comprehensive Deductible:
Collision Deductible:
Safety Features:
(Check all that apply)
1 Air Bag 2 Air bags Anti-Lock Brakes Passive Alarm
Daytime Run Lights Auto Seat Belts

Vehicle 4
Year (1986)
Make  (Ford)
Model
(Taurus GL)
Body Type (Select all that apply):
2 Dr 4Dr Pickup Van
Wagon 4WD
Vehicle ID. #
Vehicle Leased? Yes No 
Comprehensive Deductible:
Collision Deductible:
Safety Features:
(Check all that apply)
1 Air Bag 2 Air bags Anti-Lock Brakes Passive Alarm
Daytime Run Lights Auto Seat Belts

Liability Coverage
Liability Coverage:
Property Damage:
Uninsured Motorists
Personal Injury
Protection

 
Filed For Bankruptcy within the last 5 yrs? Yes No
Do you own your home? Yes No
Is Your Credit Rating: Poor Fair Good Excellent

 

Provide any additional information or comments below.