Sumners Insurance and Real Estate

114 North Main Street
PO Box 188
Clarion, IA 50525

Phone: 515-532-6653 or
1-800-778-9310
Fax: 515-532-6920

Sumners Auto Insurance Quote

Please fill out the information below and click "submit". If you make a mistake click "reset".
Only one driver and one car are required for a quote.

General Information

Name:
Address:
City:	State: ZIP:
County:	Email:
Phone Day:	( ) - Night: ( ) -
Best time to call:	AM PM

Current Auto Insurance Company:

Company Name:
Policy Exp. Date:	/ /
Premium:	$
Term:	6 Months 1 Year Other

Vehicle Information:

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

Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)

Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Anti-lock brakes?
Yes No

If vehicle is kept at an address other than that listed above, please indicate:
Location City: State: Zip:

Car #2	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #2
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No Anti-lock brakes? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip:

Car #3	Year	Make	Model	Sub Model	Body Type	Vehicle ID# (VIN)
Car #3
Name of Title Holder			Annual Mileage	Drive to school, work, station? Yes No # of miles (one way):		Car equipped w/ airbags? Yes No Anti-theft devices? Yes No Anti-lock brakes? Yes No
If vehicle is kept at an address other than that listed above, please indicate: Location City: State: Zip:

Driver Information:

(including all licensed drivers in your household)

Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Completed Drivers Education Course	Good Student	% of Vehicle Use
Driver's Name	Occupation	Relation to you	Date of birth (Mo/Day/Yr)	Male/ Female M / F	Married/ Single M / S	Completed Drivers Education Course	Good Student	# of Yrs. Licensed	#1	#2	#3
		Self		M F	M S	Y N	Y N
				M F	MS	Y N	Y N
				M F	M S	Y N	Y N
				M F	M S	Y N	Y N
Must add to:									100%	100%	100%

Driver History

If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
Yes No
If yes, please answer the following:

Driver	Date	Type of Conviction	Time	Fines	Speed Over Limit
	//			$	MPH
	//			$	MPH
	//			$	MPH
	//			$	MPH

2. Had his/her license suspended or revoked?
Answer only if "yes":

Driver	Suspended	Revoked
	Yes	Yes
	Yes	Yes
	Yes	Yes
	Yes	Yes

3. Been convicted of driving under the influence of alcohol or drugs?
Answer only if "yes":

Driver	Alcohol	Drugs
	Yes	Yes
	Yes	Yes
	Yes	Yes
	Yes	Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
Yes No
If yes, please answer the following:

Driver	Date	Cost	Fines	Injuries	At Fault	Time	Description
	//	$	$	Y N	Y N
	//	$	$	Y N	Y N
	//	$	$	Y N	Y N
	//	$	$	Y N	Y N

Mandatory Coverage's Vehicle #1 * Indicates our recomended coverage's
Bodily Injury	Medical Payment	Uninsured Motorist	Damage to Someone Else's Property
$20K/$40K

Optional Coverage's Vehicle #1
Optional Bodily Injury	Underinsured Motorist	Collision

Towing & Labor	Comprehensive	Rental

Mandatory Coverage's Vehicle #2* Indicates our recomended coverage's
Bodily Injury	Medical Payment	Uninsured Motorist	Damage to Someone Else's Property
$20K/$40K

Optional Coverage's Vehicle #2
Optional Bodily Injury	Underinsured Motorist	Collision

Towing & Labor	Comprehensive	Rental

Mandatory Coverage's Vehicle #3* Indicates our recomended coverage's
Bodily Injury	Medical Payment	Uninsured Motorist	Damage to Someone Else's Property
$20K/$40K

Optional Coverage's Vehicle #3
Optional Bodily Injury	Underinsured Motorist	Collision

Towing & Labor	Comprehensive	Rental

Comments:

PLEASE NOTE: These insurance quote's are estimates and although depict a fairly accurate figure, do not represent the true cost. Because of the many attributes that determine price and coverage an exact figure can only be given after completing a full application.