To:			insurance@howdydo.com
From:			[email]
Subject:		Auto Insurance Quote

Please accept my submission for a free Auto Insurance Quote based
upon the information I have provided below.

                        Thank You!
----------------------------------------------------
Personal Information
----------------------------------------------------
Name:			[name]
Address:		[address]
City:			[city]
State:			[state]
Zip:			[zip]
Day Phone:		[phone1]
Night Phone:		[phone2]
Fax:			[fax]
Best Time To Call:	[besttime] [ampm]
Email Address:		[email]

----------------------------------------------------
Current Auto Insurance Information
----------------------------------------------------
Company Name (not agency):	[company]
Policy Expiration Date:		[xdate]
Premium Amount:			$[premium]
Term:				[term] [other]

----------------------------------------------------
Vehicle Information
----------------------------------------------------
----- Car #1 -----
Year:			19[year1]
Make:			[make1]
Model:			[model1]
Body Type:		[body1]
Vehicle ID# (VIN):	[vin1]

Name of Title Holder:	[titleholder1]
Annual Milage:		[annual1]
Drive to school/work?:	[work1]	#of miles:	[miles1] one way
Airbags:		[airbag1]
Car Alarm:		[alarm1]

If vehicle is kept at an address other than that listed above, 
please indicate below.
Location City:		[locatecity1]
State:			[locatestate1]
Zip:			[locatezip1]

----- Car #2 -----
Year:			19[year2]
Make:			[make2]
Model:			[model2]
Body Type:		[body2]
Vehicle ID# (VIN):	[vin2]

Name of Title Holder:	[titleholder2]
Annual Milage:		[annual2]
Drive to school/work?:	[work2]	#of miles:	[miles2] one way
Airbags:		[airbag2]
Car Alarm:		[alarm2]

If vehicle is kept at an address other than that listed above, 
please indicate below.
Location City:		[locatecity2]
State:			[locatestate2]
Zip:			[locatezip2]

----- Car #3 -----
Year:			19[year3]
Make:			[make3]
Model:			[model3]
Body Type:		[body3]
Vehicle ID# (VIN):	[vin3]

Name of Title Holder:	[titleholder3]
Annual Milage:		[annual3]
Drive to school/work?:	[work3]	#of miles:	[miles3] one way
Airbags:		[airbag3]
Car Alarm:		[alarm3]

If vehicle is kept at an address other than that listed above, 
please indicate below.
Location City:		[locatecity3]
State:			[locatestate3]
Zip:			[locatezip3]

----------------------------------------------------
Coverage Information (Liability Limit For ALL Cars)
----------------------------------------------------
Choose either "Bodily Injury" AND "Property Damage" or "Single Limit"

Bodily Injury:		[bodilyinjury]
Property Damage:	[propertydamage]

Single Limit:		[singlelimit]

----------------------------------------------------
Deductibles and Misc.
----------------------------------------------------
----- Car# 1 -----
Comprehensive Deductible:	[comp1]
Full Glass:			[glass1]
Collision Deductible:		[coll1]
Towing:				[tow1]
Loss of Use:			[lossofuse1]

----- Car# 2 -----
Comprehensive Deductible:	[comp2]
Full Glass:			[glass2]
Collision Deductible:		[coll2]
Towing:				[tow2]
Loss of Use:			[lossofuse2]

----- Car# 3 -----
Comprehensive Deductible:	[comp3]
Full Glass:			[glass3]
Collision Deductible:		[coll3]
Towing:				[tow3]
Loss of Use:			[lossofuse3]

----------------------------------------------------
Driver Information (include all licensed drivers in your household)
----------------------------------------------------
----- Driver #1 -----
Driver's Name:		[drname1]
Drivers License Information.
	DL#:		[dlnumber1]
	State:		[dlstate1]
	Years Licensed:	[yearslic1]
Relation:		[relation1]
Date of Birth:		[dob1]
Sex:			[sex1]
Marital Status:		[married1]
Courses Completed Last 3 yrs.
	Drivers Ed:		[driversed1]
	Accident Prevention:  [accidentpre1]

----- Driver #2 -----
Driver's Name:		[drname2]
Drivers License Information.
	DL#:		[dlnumber2]
	State:		[dlstate2]
	Years Licensed:	[yearslic2]
Relation:		[relation2]
Date of Birth:		[dob2]
Sex:			[sex2]
Marital Status:		[married2]
Courses Completed Last 3 yrs.
	Drivers Ed:		[driversed2]
	Accident Prevention:  [accidentpre2]

----- Driver #3 -----
Driver's Name:		[drname3]
Drivers License Information.
	DL#:		[dlnumber3]
	State:		[dlstate3]
	Years Licensed:	[yearslic3]
Relation:		[relation3]
Date of Birth:		[dob3]
Sex:			[sex3]
Marital Status:		[married3]
Courses Completed Last 3 yrs.
	Drivers Ed:		[driversed3]
	Accident Prevention:  [accidentpre3]

----- Driver #4 -----
Driver's Name:		[drname4]
Drivers License Information.
	DL#:		[dlnumber4]
	State:		[dlstate4]
	Years Licensed:	[yearslic4]
Relation:		[relation4]
Date of Birth:		[dob4]
Sex:			[sex4]
Marital Status:		[married4]
Courses Completed Last 3 yrs.
	Drivers Ed:		[driversed4]
	Accident Prevention:  [accidentpre4]

----------------------------------------------------
Driver History
----------------------------------------------------
Please list ANY convictions for ANY driver convicted of 
moving traffic violations in the past 3 years

Driver:			[violationdriver1]
Date:			[violationdate1]
Type of Conviction:	[violationtype1]
Fines:			[violationfines1]
Speed Over Limit:	[violationspeed1]

Driver:			[violationdriver2]
Date:			[violationdate2]
Type of Conviction:	[violationtype2]
Fines:			[violationfines2]
Speed Over Limit:	[violationspeed2]

Driver:			[violationdriver3]
Date:			[violationdate3]
Type of Conviction:	[violationtype3]
Fines:			[violationfines3]
Speed Over Limit:	[violationspeed3]

Driver:			[violationdriver4]
Date:			[violationdate4]
Type of Conviction:	[violationtype4]
Fines:			[violationfines4]
Speed Over Limit:	[violationspeed4]

Please list ANY driver who has had license suspensions,
revocations or DUI convictions below

Driver:			[suspendeddriver1]
License Suspended:	[suspended1] / Revoked:	[revoked1]
DUI Conviction For Alcohol:	[alcohol1] / Drugs: [drugs1] 

Driver:			[suspendeddriver2]
License Suspended:	[suspended2] / Revoked:	[revoked2]
DUI Conviction For Alcohol:	[alcohol2] / Drugs: [drugs2]

Driver:			[suspendeddriver3]
License Suspended:	[suspended3] / Revoked:	[revoked3]
DUI Conviction For Alcohol:	[alcohol3] / Drugs: [drugs3]

Driver:			[suspendeddriver4]
License Suspended:	[suspended4] / Revoked:	[revoked4]
DUI Conviction For Alcohol:	[alcohol4] / Drugs: [drugs4]

Please list ANY driver involved in accidents, regardless
of fault, in the past 5 years

Driver:		[accidentdriver1]
Date:		[accidentdate1]
Description:	[accidentdescription1]
Cost:		$[accidentcost1]
Fines:		$[accidentfines1]
Injuries:	[injuries1]
At Fault:	[atfault1]

Driver:		[accidentdriver2]
Date:		[accidentdate2]
Description:	[accidentdescription2]
Cost:		$[accidentcost2]
Fines:		$[accidentfines2]
Injuries:	[injuries2]
At Fault:	[atfault2]

Driver:		[accidentdriver3]
Date:		[accidentdate3]
Description:	[accidentdescription3]
Cost:		$[accidentcost3]
Fines:		$[accidentfines3]
Injuries:	[injuries3]
At Fault:	[atfault3]

Driver:		[accidentdriver4]
Date:		[accidentdate4]
Description:	[accidentdescription4]
Cost:		$[accidentcost4]
Fines:		$[accidentfines4]
Injuries:	[injuries4]
At Fault:	[atfault4]

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Additional Comments
----------------------------------------------------
[comments]