Barfield Insurance and Financial Services, Inc.


Auto Insurance Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.
 

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information
* Name:
Address:
City:  State:   Zip:
Phone: * Work:
* Home: 
   
 Fax: 
* Email Address:

Current Policy Information
Are You Currently Insured?: No*
Yes

* If No, why not? (i.e. first time insured,
policy cancelled 3 month's ago, etc.)
If Yes, By What Company?:
Policy Expiration Date:

Current Annual Insurance Premium:

 

Driver Information
(include all licensed drivers in your household)

Driver
#1
Driver's Name
Drivers License Information
DL#:    State:    Years Licensed:
Relation
Date of Birth
Sex
Marital Status

Driving History (past 3 years)
M
F
Married
Single

Number of Tickets:
Number of Accidents:
DUI/DWAI (past 5 years):
                  SR-22 filing: Y N
                  Drivers Ed: Y N
Accident Prevention: Y N
 

Driver
#2
Driver's Name
Drivers License Information
DL#:    State:    Years Licensed:
Relation
Date of Birth
Sex
Marital Status

Driving History (past 3 years)
M
F
Married
Single

Number of Tickets:
Number of Accidents:
DUI/DWAI (past 5 years):
                  SR-22 filing: Y N
                  Drivers Ed: Y N
Accident Prevention: Y N
 

Driver
#3
Driver's Name
Drivers License Information
DL#:    State:    Years Licensed:
Relation
Date of Birth
Sex
Marital Status

Driving History (past 3 years)
M
F
Married
Single

Number of Tickets:
Number of Accidents:
DUI/DWAI (past 5 years):
                  SR-22 filing: Y N
                  Drivers Ed: Y N
Accident Prevention: Y N
 

Driver
#4
Driver's Name
Drivers License Information
DL#:    State:    Years Licensed:
Relation
Date of Birth
Sex
Marital Status

Driving History (past 3 years)
M
F
Married
Single

Number of Tickets:
Number of Accidents:
DUI/DWAI (past 5 years):
                  SR-22 filing: Y N
                  Drivers Ed: Y N
Accident Prevention: Y N

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

Car
#1
Year
Make
(Ford, etc)
Model
(Taurus, etc)
Body Type
2 Dr, 4 Dr, Cust. Van
Vehicle ID# (VIN)

Vehicle Leased?
Annual Mileage
Drive to school/work?   # of miles
  Airbags? 
Car Alarm?
Y N 
Y N       one way

1
2
None

Y  N

Anti-Lock
Brakes?

Automatic
Seatbelts?
 Comprehensive
Deductible  
Collision
Deductible
 Rental
Reimbursement 
Towing &
Labor
Y N 
Y N 

Y N
Y N
 

Car
#2
Year
Make
(Ford, etc)
Model
(Taurus, etc)
Body Type
2 Dr, 4 Dr, Cust. Van
Vehicle ID# (VIN)

Vehicle Leased?
Annual Mileage
Drive to school/work?   # of miles
  Airbags?  
Car Alarm?
Y N 
Y N       one way

1
2
None

Y  N

Anti-Lock
Brakes?

Automatic
Seatbelts?
 Comprehensive
Deductible  
Collision
Deductible
 Rental
Reimbursement 
Towing &
Labor
Y N 
Y N 

Y N
Y N
 

Car
#3
Year
Make
(Ford, etc)
Model
(Taurus, etc)
Body Type
2 Dr, 4 Dr, Cust. Van
Vehicle ID# (VIN)

Vehicle Leased?
Annual Mileage
Drive to school/work?   # of miles
  Airbags?  
Car Alarm?
Y N 
Y N       one way

1
2
None

Y  N

Anti-Lock
Brakes?

Automatic
Seatbelts?
 Comprehensive
Deductible  
Collision
Deductible
 Rental
Reimbursement 
Towing &
Labor
Y N 
Y N 

Y N
Y N
 

Car
#4
Year
Make
(Ford, etc)
Model
(Taurus, etc)
Body Type
2 Dr, 4 Dr, Cust. Van
Vehicle ID# (VIN)

Vehicle Leased?
Annual Mileage
Drive to school/work?   # of miles
  Airbags?  
Car Alarm?
Y N 
Y N       one way

1
2
None

Y  N

Anti-Lock
Brakes?

Automatic
Seatbelts?
 Comprehensive
Deductible  
Collision
Deductible
 Rental
Reimbursement 
Towing &
Labor
Y N 
Y N 

Y N
Y N

 

Liability Coverage
Tort Option
(if applicable)		 Liability
Coverage		 Property
Damage		 Uninsured
Motorists		 Personal Injury
Protection

 

Additional Considerations/Requests
Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Request" button to send us your quote request.

    

© 2010 Financial Visions

Securities and Investment Advisory Services offered through James W. Barfield as a Registered Representative and Investment Adviser Representative of Nationwide Securities, LLC P.O. Box 183137, Columbus OH 43218, (888) 753-7364. Member FINRA, SIPC. A Registered Investment Advisor. DBA Nationwide Advisory Services, Inc. in AR, FL, IL, WV. DBA Nationwide Advisory Services in MA, NY, OK. Representative of Nationwide Life Insurance Company, and affiliated companies and other companies.
Monday, September 6, 2010

Securities and Investment Advisory Services offered through James W. Barfield as a Registered Representative and Investment Adviser Representative of Nationwide Securities, LLC P.O. Box 183137, Columbus OH 43218, (888) 753-7364. Member FINRA, SIPC. A Registered Investment Advisor. DBA Nationwide Advisory Services, Inc. in AR, FL, IL, WV. DBA Nationwide Advisory Services in MA, NY, OK. Representative of Nationwide Life Insurance Company, and affiliated companies and other companies.