~ Access Insurance Group ~

Phone: 305-592-7700
Fax: 305-593-8785

Main Office:
8726 NW 26 St. #11
Doral, FL 33172

Please complete all applicable sections in the following form and you will be contacted by one of our Customer Service Representatives with a quote:

	*Required Fields
*Name
Address
City
State
Zip
*Phone
*Email

NAMED INSURED INFORMATION
Name
Sex	Male Female
Date of Birth
Marital Status
Occupation
Any Tickets?	Yes No
Driver's License #
Years Licensed

ADDITIONAL DRIVER INFORMATION
Relation to Insured
Name
Sex	Male Female
Date of Birth
Marital Status
Occupation
Any Tickets?	Yes No
Driver's License #
Years Licensed

ADDITIONAL DRIVER INFORMATION
Relation to Insured
Name
Sex	Male Female
Date of Birth
Marital Status
Occupation
Any Tickets?	Yes No
Driver's License #
Years Licensed

Do you have Prior Insurance?	Yes No
If Yes, please complete the following section: If No, skip to VEHICLE INFORMATION SECTION

PRIOR INSURANCE SECTION
Company Name:
Effective Date of Coverage	(mm/dd/yy)
Expiration Date of Coverage	(mm/dd/yy)
Prior BI Limit
Policy #
Date of Loss
Type of Loss

CLAIM HISTORY #1
Date of Claim	(mm/dd/yy)
Type of Claim
(Example: Comprehensive, Collision PIP, PD, etc.)
Amount Paid

CLAIM HISTORY #2
Date of Claim	(mm/dd/yy)
Type of Claim
Amount Paid

CLAIM HISTORY #3
Date of Claim	(mm/dd/yy)
Type of Claim
Amount Paid

VEHICLE INFORMATION SECTION
VEHICLE #1
Y ear
Make
Model
Miles Driven to Work
Primary Use	Personal Business
Air bags	Yes No
ABS	Yes No
Alarm	Yes No

VEHICLE #2
Y ear
Make
Model
Miles Driven to Work
Primary Use	Personal Business
Air bags	Yes No
ABS	Yes No
Alarm	Yes No

VEHICLE #3
Year
Make
Model
Miles Driven to Work
Primary Use	Personal Business
Air bags	Yes No
ABS	Yes No
Alarm	Yes No

VEHICLE #4
Year
Make
Model
Miles Driven to Work
Primary Use	Personal Business
Air bags	Yes No
ABS	Yes No
Alarm	Yes No

The information you will submit will be stored securely and will not be sold or given to any third party except where required to do so by law. Submission of this form constitutes your consent for a representative of Access Insurance Group to contact you even if your phone is on the National Do Not Call List.