Bennion Taylor Insurance

461 West Murray Blvd, Murray, UT 84123

801-263-9883

Personal Auto Quick Quote Sheet

Named Insured Information

Contact Name
CARLOS MURCIA Email
cmmd01@hotmail.com Phone #
8018958243

Named Insured
Carlos Mauricio Murcia Díaz SSN# DOB

Married: □ Yes □ No If yes, what is spouse name Date of Birth Spouse SSN#

Physical Address :
4197 S Main Street Apto 142
Mailing Address: (If
different)

Years with prior insurance □ None □ 1-3 □ 3-5 □ 5+

Prior Insurance Carrier Current Expiration Date

Current Insurance Limits □ State Minimums □ 100,000 □ 300,000 □ 500,000

Policy Term Needed □ 6 month policy □ 12 month policy

Auto Liability Limits Needed □ State Minimums □ 100,000 □ 300,000 □ 500,000

Driver Information
Driver License Current Good Student
Driver Name DOB # SSN # Occupation (≥ B Average)
Carlos Mauricio Murcia Díaz 238703755 Forklift operator

*good student discount can only be added if you can provide documentation confirming grade point average is B or higher in the last 6 months.

Vehicle Information
Name Vehicle is Main Driver for Comprehensiv Collision
Year Make Model Titled in this vehicle VIN # e Deductible Deductible

2015 BMW 328i Utah yes WBA3A5G59FNS84312

□ 500 □1000 □ 500 □1000

□ 500 □1000 □ 500 □1000

□ 500 □1000 □ 500 □1000

□ 500 □1000 □ 500 □1000

□ 500 □1000 □ 500 □1000

□ 500 □1000 □ 500 □1000

1/2
 Bennion Taylor Insurance
461 West Murray Blvd, Murray, UT 84123
801-263-9883

If any household driver has had a ticket or accident in the last 3 years complete the below table
Violation
Driver Date Description of violation

If any losses in the last 5 years complete the below table.

Loss Date Description of claim/loss Amount of Loss

General Information (y / n)
1 Are all Drivers in the household total abstainers from tobacco and alcohol? (Note: discount applies if verification is received)
n
2 Are any of your household vehicles driven out of state more then 30 days per year?
n
3 Has any automobile insurance been cancelled or non-renewed in the last 3 years?
n
4 Are any of your household vehicles used in any home or commercial business venture?
n
4a If yes, Explain:
n
5 Do you have a renters or home policy?
n
5a If yes, would you like us to quote it?
n

Additional Comments
I would like to get full coverage

Signature of Person Completing this Form Title

2/2