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Shaw-Day Insurance
Agency, LLC

1700 E. Prien Lake Rd.
Suite 1
Lake Charles, LA 70601
(Click for Office Map/Directions)
 
E-Mail:
quotes@louisiana-auto-
insurance-quote.com

Local Phone:
337-474-0006

Fax:
337-474-0008


Visit Our Agency's Other On-Line Quote Forms and Start Saving!
 
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Flood Insurance Quote

Motorcyle Ins. Quote

R.V. Insurance Quote

Boat Insurance Quote

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Life Insurance Quote

Cancer Insurance Quote

Businessowners Quote

Commercial Auto Quote

Group Benefits Quote

About Our Agency

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Louisiana-Auto-Insurance-Quote.com - Louisiana car insurance discounts
 
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 Louisiana)
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
 
Medical and/or
PIP 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
 
Medical and/or
PIP 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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