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Legacy Insurance Agency
2133 N Hobart St,
Pampa, TX 79065

Phone:
(806) 665 4800
(866) 764 6400
Fax:
(806) 669 2555
E-mail:
legacy@legacy-ins.com

Agents:
Pat Warren
pat@legacy-ins.com

Katrina Neff
katrina@legacy-ins.com

Carrier Affiliations

Call us: (806) 665 4800

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General Information

Company/Business Name:*

Business Address:

City:

State:

Zip/Postal Code:

Country:

United States

Phone:

Fax (Optional):

Contact Person Information

First Name: *

Last Name:

Day Phone:

Night Phone:

Best Time To Call (HH:MM):

AM PM

E-mail Address: *

Vehicle 1 Information

Year:

Make (Ex: Mercedes-Benz):

Model (Ex: E320 CDI):

Style or Body Type (Ex: Truck,Tow-truck,Bobtail,etc.) :

VIN # (Optional):

Yearly Mileage:

Vehicle Value ($):

Radius of Operation (In miles):

List Custom Equipment (Ex: Rack, Tool Box etc ):

Equipment Value ($):

Vehicle 1 Coverage

Limits of Liability:

$30/60 BI / 25 PD	$50/100 BI / 50 PD
$100/300 BI / 50 PD	$250/500 BI / 100 PD
$1 Million	Others

Comprehensive & Collision:

No Coverage	$250 Deductible
$500 Deductible	$1000 Deductible
Others

Vehicle 2 Information

Year:

Make (Ex: Mercedes-Benz):

Model (Ex: E320 CDI):

Style or Body Type (Ex: Truck,Tow-truck,Bobtail,etc.) :

VIN # (Optional):

Yearly Mileage:

Vehicle Value ($):

Radius of Operation (In miles):

List Custom Equipment (Ex: Rack, Tool Box etc ):

Equipment Value ($):

Vehicle 2 Coverage

Limits of Liability:

$30/60 BI / 25 PD	$50/100 BI / 50 PD
$100/300 BI / 50 PD	$250/500 BI / 100 PD
$1 Million	Others

Comprehensive & Collision:

No Coverage	$250 Deductible
$500 Deductible	$1000 Deductible
Others

Current Insurance Information

Insurance Company Name:

Policy Expiry Date (MM/DD/YYYY):

Premium Amount ($):

Term (Years):

Same Company Policy Since?

Driver 1 Information

Name:

Sex:

Male Female

DL # (Optional):

Date of Birth (MM/DD/YYYY):

Marital Status:

Single Married

Education:

Number of Years Licensed In US:

Does Driver Need SR22 Filing?

Yes No

One Way Daily Commute (In Miles):

Driver 2 Information

Name:

Sex:

Male Female

DL # (Optional):

Date of Birth (MM/DD/YYYY):

Marital Status:

Single Married

Education:

Number of Years Licensed In US:

Does Driver Need SR22 Filing?

Yes No

One Way Daily Commute (In Miles):

Accidents / Violations In Last 5 Years	(Driver 1)	(Driver 2)
Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.:
Accidents - Non Chargeable:
Accidents - Chargeable:
Chargeable Accident Cost ($):
Major Violations - Drunk driving, Reckless, Hit And Run, etc.:

Any additional comments or information that might be helpful in your quote:

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