Car Insurance quote

Please complete all sections on the following forms.

A Shackelford representative will contact you with an approximate quotation based on this information.


      Name: 
   Address: 
      City:    State:    Zip: 
Home Phone:    Work Phone:    Fax: 
    E-Mail:

How do you want to receive your proposal?
Are you in need of an SR-22?
Indicate current insurance carrier:
Policy renewal date:
Has any driver had a lapse in coverage in the past year?
If yes, indicate driver and dates of lapse(s):
Does any driver have a company car provided for their regular use (driven home nightly)? If yes, indicate driver:
Has any driver incurred any tickets, violations, accidents (including not-at-fault), or made any claims in the last 5 years?
If so, indicate driver and provide details, including dates, below.

                                       VEHICLE IDENT.        COST
             YEAR  MAKE      MODEL     NUMBER (VIN)          NEW
Vehicle #1 -     
Vehicle #2 -     
Vehicle #3 -     
Vehicle #4 -     


                                    ANTI-THEFT            ANTI-LOCK
             USE          AIRBAGS   DEVICE/TYPE*          BRAKES
Vehicle #1 -    
Vehicle #2 -    
Vehicle #3 -    
Vehicle #4 -

*Audio alarm, alarm with engine "kill" switch, computer chip key, hidden transmitter, VIN etching on glass or engine; was the device factory-installed or aftermarket?

(List names of all household residents aged 14 years or older,
even if person does not drive or is not yet licensed)

                                  DATE OF    MALE OR
            DRIVER NAME           BIRTH      FEMALE    MARITAL STATUS
Driver #1 -    
Driver #2 -    
Driver #3 -    
Driver #4 -    


                                                            DEFENSIVE
                                      VEHICLE               DRIVING IN
                                      DRIVEN   VEHICLE      LAST THREE
            RESIDENCE TYPE             MOST    USE          YEARS?
Driver #1 -      
Driver #2 -      
Driver #3 -      
Driver #4 -

To submit this quote sheet back to us, On your web browser go to FILE and click on SEND TO== FAX RECIPIENT. My Fax number is 806 364-2442

Site Created By
J and R Computers
rrangel@wtrt.net

To submit this quote sheet back to us, On your web browser go to FILE and click on SEND TO== FAX RECIPIENT. My Fax number is 806 364-2442

Site Created By J and R Computers rrangel@wtrt.net

Site Created By
J and R Computers
rrangel@wtrt.net