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NEXUS AUTO FORM
Nexus Insurance Auto Quote
*E-Mail:Valid e-mail is required
*First Name:
*Last Name:
Address Line 1:
Address Line 2:
City:
*State:
*Zip Code:
*Phone:
Current Carrier Information
Who is your current insurance carrier (not agency)?
Insurance Carrier Name:
What is the expiration date of your current automobile policy?
Expiration date:mm/dd/yyyy
Vehicle Information
Vehicle #1:Year, Make & Model
VIN#1:
Vehicle Use Vehicle #1:
*Add a 2nd vehicle?
Yes No 
Vehicle #2:Year, Make & Model
VIN#2:
Vehicle Use Vehicle #2:
*Add a 3rd vehicle?
Yes No 
Vehicle #3:Year, Make & Model
VIN#3:
*Vehicle Use Vehicle #3:
*Add a 4th vehicle?
Yes No 
*Vehicle #4:Year, Make & Model
*VIN#4:
*Vehicle #4:
Driver #1 Information
*Driver 1 Name:
*Date of Birth:mm/dd/yyyy
*Marital Status:
Single Married Divorced Widowed 
*Residence Type:
Own Home Rent Live With Parents 
Education:
Driver`s License No:
Which car do you drive?
Have you had any ticket or accident within the last 5 years?
*Add a 2nd driver?
Yes No 
Driver #2 Information
*Driver 2 Name:
*Date of Birth:mm/dd/yyyy
*Marital Status:
Single Married Divorced Widowed 
*Driver Identification No:
*Residence Type:
Own Home Rent Live WIth Parents 
*Education:
*Driver`s License No:
*Which car do you drive?
*List Traffic Violations:
*List/Describe Any Accidents:
*Relation to Driver 1:e.g. son, daughter ...
*Add a 3rd driver?
Yes No 
Driver #3 Information
*Driver 3 Name:
*Date of Birth:mm/dd/yyyy
*Marital Status:
Single Married Divorced Widowed 
*Driver Identification No:
*Residence Type:
Own Home Rent Live WIth Parents 
*Education:
*Driver`s License No:
*Which car do you drive?
*List Traffic Violations:
*Relation to Driver 1:e.g. son, daughter ...
*List/Describe Any Accidents:
Requested Coverage
Coverage is listed below as: per person/per accident/property damage.
Liability Coverage & Limits:Person/Accident/Property
Unisured Coverage is listed below as: per person/per accident.
Uninsured/Underinsured Motorist:Person/Accident
Uninsured Motorist Property Damage:
Comprehensive/Other Than Collision
Deductible Vehicle #1:
Deductible Vehicle #2:
Deductible Vehicle #3:
Deductible Vehicle #4:
Collision
Deductible Vehicle #1:
Deductible Vehicle #2:
Deductible Vehicle #3:
Deductible Vehicle #4:
Other
Towing Coverage:
Yes No 
Comment or Questions:
AGENT NAME (If Known):
Referral Person Name (If Any):
Doc Attachment 
 

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