Auto


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Theiss Insurance Agency offers Auto Insurance Coverage throughout Harris and surrounding counties. We will be happy to review your coverage to make sure you are getting the most amount of insurance for the least amount of money. We can offer you a wide variety of coverage options!

 

Vehicle Insurance Products:

  • Standard Auto
  • RV & Travel Trailer
  • Motorcycle
  • Watercraft
  • ATV

You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.




Personal Information


Name Email Address
Address Day Phone
City Night Phone
State  Zip  Best Time to Call  
AM  
PM
Preferred Contact Method Email  
Phone

Current Auto Insurance Information


Company Name Policy Expiration
Premium Amount Term
Are You A Homeowner?
Y  N
Insurance
Carrier

Vehicle Information (include all cars you or your family members own or lease)


Car #1

Year
Make
Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Milage
Drive to school/work?
# of miles
(one way)
  Airbags  
Car Alarm
Y N
Y  N
Y  N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:  
State:  
Zip:
Driver Name

Car #2 (enter info)

Car #3 (enter info)

Car #4 (enter info)

Liability Limit for ALL Cars



Choose either   Bodily Injury   and   Property Damage

or   Single Limit


Bodily Injury
        

Property Damage


Single Limit

The minimum auto liability coverage amount required by the states of Texas and Arkansas is $30,000 for each injured person, up to a total of $60,000 per accident, and $25,000 for property damage.

Other Coverages


Personal Injury Protection/Medical Payments


Uninsured/Underinsured Motorist – Bodily Injury


Uninsured/Underinsured Motorist – Property Damage


Texas and Arkansas insurers must offer you $2,500 in Personal Injury Protection, but you can buy more. Texas and Arkansas require insurance applicants to reject PIP coverage in writing if they don’t want it.

Deductibles and Misc.



Car#

Comprehensive Deductible

Collision Deductible

Towing

Rental Reimbursement

1



Yes

Yes

2



Yes

Yes

3



Yes

Yes

4



Yes

Yes

Driver Information (include all licensed drivers in your household)


Driver #1

Driver’s Name
Drivers License Information
DL#:
State:
Yr’s Licensed:
Relation
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married Single
Drivers Ed: 
Defensive Driving;
Drug & Alcohol Awareness: 
Driver’s SSN

Driver #2 (enter info)

Driver #3 (enter info)

Driver #4 (enter info)

Driver History


List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver
Date
Type of Conviction
Speed Over Limit
mph
mph
mph
mph
List ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  
List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Injuries
At Fault
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes

Additional Comments





Please give any additional comments you feel appropriate for this quotation.


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