Phone:
Toll Free:
866-352-3075
Direct Line:
619-461-0111
Fax Number:
619-639-0313
Mailing Address:
Rod Galloway
Insurance Agency
9019 Park Plaza Dr. #G
La Mesa, CA
91942
Our carriers offer 12-15% discount off your Home and Auto Insurance when we write both policies.
"Remember, All Our Policies Come with an Agent!"
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DRIVER INFORMATION
#1
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Cycle Safety Course?
# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION
#2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Cycle Safety Course?
# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
VEHICLE #1
INFORMATION
Year of vehicle:
Make & Model:
Is this a 4 Wheeler?:
If Yes, Describe:
Annual Mileage:
# of CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #1
COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50
PD
$100/300 BI / 50
PD
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Is this a 4 Wheeler?:
If Yes, Describe:
Annual Mileage:
# of CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #2
COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 50
PD
$100/300 BI / 50
PD
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
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COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
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