Dakkak Insurance, LLC - Automobile Insurance Quote

We Protect You and Your Family

At Dakkak Insurance, our plan is to be your Insurance Agent of choice. We are a full service agency and we have the capability to provide protection for all of your needs. By reviewing your entire portfolio, we can insure you have no gaps in coverage, lowering your personal risk while protecting what’s important to you. Our agency offers the peace of mind that comes with full protection and a solid service guarantee.

Automobile Insurance Quote

Your Full Name:
E-mail address to send information:
Property Address:
City:
State:
Zip:
County:
Phone number where you would like to be contacted:
Best time to reach you?
Best method to contact you:

Have you had continuous coverage for the last 12 months:
If not, why not?
Present auto insurance company:
Expiration Date:
Own your own home:

Car #1
Year:
Make:
Model:
Predominant vehicle use:
Annual Mileage:
Type of anti-theft device on vehicle:
Anti-lock brakes:
Vehicle ID number (Vin#):

Car #2
Year:
Make:
Model:
Predominant vehicle use:
Annual Mileage:
Type of anti-theft device on vehicle:
Anti-lock brakes:
Vehicle ID number (Vin#):

Car #3
Year:
Make:
Model:
Predominant vehicle use:
Miles to Work (one way):
Annual Mileage:
Type of anti-theft device on vehicle:
Anti-lock brakes:
Vehicle ID number (Vin#):

Driver #1 Information
Driver Name:
Occupation:
Business:
Retired:
Date of birth:
Gender:	Male Female
Marital Status:
Moving violations in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each violation:
Accidents in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each accident:

Driver #2 Information
Driver Name:
Occupation:
Business:
Retired:
Time at current job:
Date of birth:
Gender:	Male Female
Marital Status:
Moving violations in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each violation:
Accidents in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each accident:

Driver #3 Information
Driver Name:
Occupation:
Business:
Retired:
Time at current job:
Date of birth:
Gender:	Male Female
Marital Status:
Moving violations in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each violation:
Accidents in last 5 years:	0 1 2 3 4 5
Please provide the date and a brief description of each accident:

Liability Limit for All Cars
Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury:
Property Damage:
Single Limit choose one:
Uninsured Motorist coverage:
Medical payments:
Levels of current Uninsured Motorist coverage:

Car #1
Deductible Comprehensive:
Deductible Collision:
Tow:
Loss of use:

Car #2
Deductible Comprehensive:
Deductible Collision:
Tow:
Loss of use:

Car #3
Deductible Comprehensive:
Deductible Collision:
Tow:
Loss of use:

Comments:

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