Insurance Niches in Time by
12 Times

425-432-4999

Auto Insurance

Home Insurance

Business Insurance

Parents of Teen Drivers

Thank you for giving 12 Times Better Insurance an opportunity to earn your business. This is the most detailed quote template that can answer multiple carriers questions. If your unsure of a particular question, or if it does not apply, just go on to the next section.

Better Insurance Niches in Time, by 12 Times.

Gender *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Current Insurance Provider

Current Policy End Date

Length of Coverage (Months and Years)

If your insurance is not active, when did it cancel?

Do you know your Liability Limits are on your current or previous insurance?

Do you Own or Rent your home?

AAA MEMBER?

Driver 1-Date of birth

Gender

Marital status

#1-USA Year/Month first licensed or age

Driver's license number and State.

Highest Level of Education

#1-Moving or non-moving violations past 5 years-list approximate month/year

#1-Accidents at-fault or non-fault past 5 years-list approximate month

Name of Driver 2

Driver 2 -DOB

Gender *

Marital status

Relationship *

Driver's license number and State.

#2-USA Year/Month first licensed or age

#2-Moving or non-moving violations past 5 years-list approximate month

#2-Accidents at-fault or non-fault past 5 years-list approximate month

Name of Driver 3

Driver 3-DOB

Driver's license number and State.

#3-USA Month/Year first licensed or age.

Driver's license number & State

#3-Moving or non-moving violations past 5 years-list approximate month

#3-Accidents at-fault or non-fault past 5 years-list approximate month

#3 - If Student, please list Grade Point Average

Liability Limit

Uninsured Motorist Bodily Injury

Uninsured Motorist Property Damage

Do you want Personal Injury Protection?(PIP)

Vehicle 1 year, make, model *

Vehicle 1 VIN

Vehicle 1 - Comprehensive Deductible

Vehicle 1 - Collision Deductible

Vehicle 1- Rental

Vehicle 1 - Towing

Vehicle 1 - Average Commute in Miles

Vehicle 1 - How many days per week do you commute?

Annual Miles Vehicle 1

#1 Month/Year purchased vehicle?

Are you towing anything? *

Vehicle 2 year, make, model

Vehicle 2 VIN

Vehicle 2 - Comprehensive Deductible

Vehicle 2 - Collision Deductible

Vehicle 2- Rental

Vehicle 2 - Towing

Commute miles one-way and days per week

Annual Miles Vehicle 2

#2 Month/Year purchased vehicle?

Commute miles one-way and days per week

Month/Year purchased vehicle

Vehicle 3 year, make, model

Vehicle 3 - Comprehensive Deductible

Vehicle 3 - Collision Deductible

Vehicle 3- Rental

Vehicle 3 - Towing

Vehicle 3 VIN

Would you consider a Auto Homeowners package for the best prices?

Submission Validation

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3108 A Street SE, Suite A, Auburn, WA 98002 | 425-432-4999 | 253-249-7581