Farmers Auto Insurance Form

Automobile Insurance Form

Exclusively for the Albuquerque,New Mexico Area

For a free quote please fill out the form below as completely as possible. If you have more than two cars, please fill out another form. (Remember to mark the multiple car option in the discounts section.).

Personal Information:

Name:
Address:
City:
State:	Zip Code:
Prefer to be contacted via:
E-Mail address:
Telephone number:
Marital Status:
SS#:	Click here to find out more on providing your SS#

Do we have your permission to use your FARA score:
(For Yes you must have filled in your SS# above)

If the above is answered No we will need the next question answered and we will try to provide an accurate as possible quote for you

Do you feel your credit rating is

Do you currently have insurance?

If yes, which insurance company:

Have you been in any accidents or
had any moving violations (tickets) in the past 3 years:

If yes, explain . .

Automobile Information:

	Vehicle # 1	Vehicle # 2

Driver's Name:
Driver's Birth Date:
Gender:

Year:
Manufacturer:
Model:
Body Style:

Annual Mileage:
Vehicle Use:
Antilock Brakes (ABS):
Passive Restraint Type:

Discounts

Multiple Cars:
Non-Smoker:
Defensive Driver Course:
Good Student:
Homeowners Insurance with Farmers:
Age of 50+:
Yes Program:

Coverages

	Vehicle # 1	Vehicle # 2

Bodily Injury (Liability):
Property Damage:
Uninsured Motorist:
Medical:
Comprehensive Deductible:
Collision Deductible:
Towing and Road Service :
Loss of Use (Rental Car):

Comments or additional drivers (age, gender, accidents):

Thank you

If you have any questions, contact Canfield Insurance Agency at (505) 857-0222 or

Email me at rcanfield@canfieldinsurance.com