Woltz Insurance Auto Quote Form
Fast and Easy Information Form
Auto Insurance Quote Sheet
Complete out our Fast and Easy Information Form below.  You'll receive a SUPER FAST quote by
e-mail, postal mail, fax or
phone - your choice! 		If you have any questions, please feel free to contact us via e-mail at: woltz@woltzinsurance.com or call us at (716) 664-3890.
Personal Information

Name: (Required)
Address: (Required)
City: State: ZIP:
Phone:
Fax: (optional)
E-Mail: (optional)
Date of Birth:
Marital Status: Single   Married   Divorced   Widowed

Drivers License State:
Drivers License #:
Social Security #:
Tickets in Last Five Years:
(If none, leave blank)
Accidents in Last Five Years:
(If none, leave blank)
Are you Currently Insured? Yes  No
Have you taken Defensive Driving in the past 3 years? Yes  No
How many miles a day do you travel one way to work?

Vehicle Information

Year:    Make:    Model:   
Vehicle Identification #:   
Anti-Lock Brakes? Yes  No    Air Bags?
Daytime running lights? Yes  No    Alarm?
Comprehensive Deductible:    Other:
Collision Deductible:    Other:
Liability:    Other:
Property Damage:    Other:
Medical Payments:    Other:
Uninsured/Underinsured Motorist:    Other:
Additional Information:
How would you preferred to be contacted? Phone  E-Mail   Mail  Fax
If we need to speak to you via phone, when is the best day and time to call?

How did you hear about woltzinsurance.com?