Auto Insurance Services

	Accurate & Affordable Insurance Services
	1-(800)-796-2418	License # 0G00787

Welcome to Accurate & Affordable Insurance Services. We look forward to serving you

Thank you for your interest in our automobile insurance services. Accurate & Affordable Insurance will use the information you provide here for the sole purpose of getting you the most accurate quote possible.

About You
Name:
Email Address:
Street Address
City
State
Zip
Gender	Male Female
Date Of Birth (MM/DD/YYYY)
Date First Licensed (MM/DD/YYYY)
Marital Status
State Licensed
Are You Currently Insured ?	Yes No
About Your Vehicle
Vehicle Manufacturer
Model
Year First Registered
VIN # (If Available)
Vehicle Usage	This Vehicle is used for driving to and from work, and for pleasure purposes This vehicle is used for commercial use
If used for commercial use, please specify your type of business
Is your vehicle garaged overnight at the address given above	Yes No
About Your Insurance Needs
Approximate Annual Milage
Type of Insurance Required
General Bodily Injury Limits Requested
Drivers License #
About Your Driving Record
Do you currently have any citations?	Yes No
Citation #1:
Citation #2:
Citation #3:
Citation #4:
Citation #5:
Have you been found "At Fault" for any accidents within the past 36 Months?	Yes No

Privacy Notice: By clicking on the "Submit Form" button, you are giving Accurate & Affordable Insurance Services permission to use this information solely for the purpose of providing you with quotes. We will never sell, give, or in any way transfer your personal information to any person or entity other than the insurance carriers that Accurate & Affordable Insurance Services works with. In some cases insurance companies we work with may request a credit score

Accurate & Affordable Insurance Services, Inc.
PO Box 8247
Fountain Valley, CA 92728
1-(800)-796-2418
Phone (714) 943-2103, Fax (888) 908-7001