ValueMaxInsurance.com - low cost Florida auto insurance. Save money on FL car insurance, get a free Florida SR22-FR44 automobile insurance quote.

Discounts available for:
Safe Driver, Anti-Lock Brakes, Air bags,
Anti-Theft devices, Homeowners, Prior Insurance,
Multiple Vehicles, Multiple Policies, Good Student,
Automatic Payments, Paid In Full, Retired driver,
plus many more.

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SuperSaver Auto Insurance Discount Review.

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On-Line Automobile Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be Florida)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Primary Insured's Occupation:

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

DRIVER INFORMATION #1
Name:		Birthdate:
Sex (M/F):		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	If YES to SR22 filing, why needed? (list accident/cite)
Give details on all violations or accidents:

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS: If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:		Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits

Select Comprehensive Deductible:

Select Collision Deductible:

Rental Car & Towing Coverage?	YES NO

Uninsured Motorists Coverage?	YES NO

PIP/PD Coverage?	YES NO

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits	- - - Liability Limits Must Match Vehicle #1 - - -

Select Comprehensive Deductible:

Select Collision Deductible:

Rental Car & Towing Coverage?	YES NO

Uninsured Motorists Coverage?	YES NO

PIP/PD Coverage?	YES NO

Comments or Remarks: (List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:

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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Contact ValueMax Insurance at: 1-305-222-9895
Powered by Diaz Insurance Group a division of Diaz Insurance, Inc.

Value Max Insurance | 9786 SW 8th Street | Miami, FL 33174 | LOCAL PHONE: 305-222-9895 | FAX: 305-220-0803
EMAIL: quotes@ValueMaxInsurance.com | FL INSURANCE LICENSE#A067704
Our Mission Statement is simple: Help You Save Money On Your Insurance Needs!

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