Look at the LOW RATES some of our Current Clients Are Paying!
"Full Coverage on 2008 Mustang, Only $82 Per Month!"
25 year old female, with one accident, on 2008 Ford Mustang - HUGE DISCOUNT!
"Liability on Chevy Truck, Only $22 Per Month!"
49 year old male, liability only on 1996 Chevy Truck - SUPER SAVINGS!
"Full Coverage on 2007 Ford Edge, Only $79 Per Month!"
34 year old female, with full coverage on 2007 Ford Edge - SAME DAY POLICY!
DRIVER INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
If YES to SR22 filing, why needed? (list accident/cite)
Give details on all violations or accidents:
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS: If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:
VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible:
Rental Car & Towing Coverage?
YES
NO
Uninsured Motorists Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits
- - - Liability Limits Must Match Vehicle #1 - - -
Select Comprehensive Deductible:
Select Collision Deductible:
Rental Car & Towing Coverage?
YES
NO
Uninsured Motorists Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
Comments or Remarks:
(List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:
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Our Goal:
Wardwell Insurance Agency is a Texas insurance agency with highly qualified professionals committed to finding the best coverages and prices for your Texas car insurance quotes and online Texas automobile insurance rates.
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Wardwell Insurance Agency has been proudly serving drivers in the Houston, TX area for many years. We offer personal service,
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