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SKORUSA.com - Auto Insurance Quote Form
Your Contact Information
E-Mail:*
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
County:*
How long have you lived at this address? (If less than 3 years, provide previous address)*
Phone:*
Do you own your home?*
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:*
 
Approx Current Premium*
Requested Effective Date*
 
# of yrs with Current Carrier*
Vehicle Information
Vehicle #1: Yr, Make, Model*
Ownership?*
Lien
Leased
Owned (No Lien/No Lease)
VIN#1:*
Vehicle Use Vehicle #1:*
State vehicle registered in?*
Name of titleholder?*
Add a 2nd Vehicle?*
Yes No 
Vehicle #2: Yr, Make, Model*
Ownership?*
Lien
Leased
Owned (No Lien/No Lease)
VIN#2:*
Vehicle Use Vehicle #2:*
State vehicle registered in?*
Name of titleholder?*
Add a 3rd vehicle?*
Yes No 
Vehicle Information Continued
Vehicle #3: Yr, Make & Model*
Ownership?*
Lien
Leased
Owned (No Lien/No Lease)
VIN#3:*
Vehicle Use Vehicle #3:*
State vehicle registered in?*
Name of titleholder?*
Add a 4th vehicle?*
Yes No 
Vehicle #4: Yr, Make & Model*
Ownership?*
Lien
Leased
Owned (No Lien/No Lease)
VIN#4:*
Vehicle #4:*
State vehicle registered in?
Name of titleholder?*
Driver #1 Information (NOTE ALL LICENSED AGED MEMBERS MUST BE LISTED ON POLICY)
Driver 1 Name:*
Occupation*
Date of Birth:*
 
Marital Status:*
Single Married Divorced Widowed 
Education:
Does this Person Own a Smart Phone?*
Yes an I-Phone
Yes an Android
No
Driver`s License #:(If not IL, indicate state)*
Which car does this driver drive?*
List Traffic Violations last 5 yrs:*
List/Describe Any Accidents last 5 yrs: (date/type of loss/amount paid)*
Add a 2nd driver?*
Yes No 
Driver #2 Information
Driver 2 Name:*
Occupation*
Date of Birth:*
 
Marital Status:*
Single Married Divorced Widowed 
Education:*
Does this Person Own a Smart Phone?*
Yes an I-Phone
Yes an Android
No
Driver`s License #:(If not IL, indicate state)*
Which car does this driver drive?*
List Traffic Violations last 5 yrs:*
List/Describe Any Accidents last 5 yrs: (date/type of loss/amount paid)*
Relation to Driver 1:*
Add a 3rd driver?*
Yes No 
Driver #3 Information
Driver 3 Name:*
Occupation*
Date of Birth:*
 
Marital Status:*
Single Married Divorced Widowed 
Education:*
Does this Person Own a Smart Phone?*
Yes an I-Phone
Yes an Android
No
Driver`s License #: (If not IL, indicate state)*
Which car does this driver drive?*
List Traffic Violations last 5 yrs:*
Relation to Driver 1:*
List/Describe Any Accidents last 5 yrs: (date/type of loss/amount paid)*
Add a 4th driver?*
Yes No 
Driver #4 Information
Driver 4 Name:*
Occupation*
Date of Birth:*
 
Marital Status:*
Single Married Divorced Widowed 
City:*
Education:
Does this Person Own a Smart Phone?*
Yes an I-Phone
Yes an Android
No
Drivers License #: (If not IL, indicate State)*
Which car does this driver drive?*
List Traffic Violations Last 5 yrs:*
Relation to Driver 1:*
List/Describe Any Accidents last 5 yrs: (date/type of loss/amount paid)*
Requested Coverage
Coverage is listed below as: per person/per accident/property damage.
Liability Coverage & Limits:*
Unisured Coverage is listed below as: per person/per accident.
Uninsured/Underinsured Motorist:
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 
Rental Reimbursement*
Yes No 
Are any vehicles used in a business? (If yes, which vehicle and what kind of business use?)*
Any drivers qualify for Good Student Discount? If Yes, who?*
Are any drivers away at school?*
If Yes, Who? and is school more than 100 miles away? (Type NA, if non-applicable)*
Personal Umbrella Quote? If Yes, indicate 1, 2 or 3 million*
Would you like a home, condo or renters insurance quote? (If Yes, Complete Home Form Too)*
Would you like a life insurance quote?*
How did you hear about us?
Comments, Questions, Additional Info
NO COVERAGE OF ANY KIND IS BOUND OR IMPLIED BY SUBMITTING INFORMATION VIA THIS ONLINE FORM
* By submitting this information, you agree that we may use information from you and other sources, such as driving, claims, and insurance credit score histories, to calculate an accurate price for your insurance. You also agree for us to contact you via telephone, email, mail or text regarding this quote, even if you are on the Do Not Call or Do Not Contact/Mail listing.
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