From:

Name:

Phone:

E-mail:

Address:

City: State: AK CA ID NV OR WA Zip:

Gender: Male Female

Presently, Zolezzi Insurance agency can only issue quotes for Oregon.

Occupation:

Employer:

Present Insurance:

Company:

Policy Number:

Expiration Date:

number of months
continuous coverage:

number of months
loss free

If you answered 'Yes' for accidents or tickets, please provide the date and information regarding at-fault accidents or tickets.

Coverage:

Bodily Injury: $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $100,000 $300,000 $500,000

Property Damage: $25,000 $50,000 $100,000 $300,000 $500,000

Comp. Deductible: $100 $200 $250 $500 $1000 $0

Collision Deductible: $100 $200 $250 $500 $1000 $0

Towing Coverage: Yes No

Rental Coverage: Yes No

Vehicles:

Homeowner's/Renter's insurance: Homeowner Renter None

Business Exposure: Yes No

If so, please explain in the comments area below.

Enter any additional comments/questions here: