Auto Insurance Quote Form
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Please complete the information below for a Auto Quote

Vehicle Information / Información del vehículo

Kilometraje anual promedio

Driver Information / Información del conductor

Número de licencia de conducir y estado de emisión

Años de experiencia de conducción

Coverage Needs / Necesidades de cobertura

Proveedor de seguros actual (si lo hay)

Niveles de cobertura actuales y deducibles (si corresponde)

Tipo de cobertura deseada (solo responsabilidad civil, cobertura total, cobertura integral, colisión, otra)

Additional Information / Información Adicional

¿Algún otro conductor en el hogar?

En caso afirmativo, indique los nombres y la fecha de nacimiento.

Por favor, cargue una copia de su licencia de conducir y tarjeta de seguro actual.

Authorization to Obtain Auto Information for Auto Quote

Autorización para Obtener Información del Vehículo para Cotización de Seguro de Auto

Authorization to Obtain Auto Information for Insurance Quote

I, the undersigned, authorize Priscilla Cabrera to obtain and review information regarding my automobile, including but not limited to vehicle details, driving history, insurance history, and other relevant data, for the exclusive purpose of preparing an accurate and complete auto insurance quote on my behalf.

I understand and agree to the following:

  1. Purpose of Authorization
    • This authorization allows Priscilla Cabrera to collect and use my automobile information solely for the purpose of providing an auto insurance quote.
  2. Confidentiality
    • All information obtained under this authorization will be treated as confidential and will not be shared with any third party except as necessary to generate the insurance quote.
  3. Voluntary Consent
    • I understand that my consent is voluntary. I may refuse to sign this authorization, but doing so may limit the ability to provide a complete and accurate insurance quote.
  4. Revocation of Consent
    • This authorization will remain in effect until I revoke it in writing. I understand that revocation will not affect any actions taken based on this consent prior to receiving my written revocation.
  5. Limitations of Use
    • The information accessed will not be used for any purpose other than preparing the requested insurance quote.

By signing below, I confirm that I have read and understood this authorization and that I consent to the release of my auto information as described.

Make an Appointment: You will be able to choose from available Appointments on the next step
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