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John L. Sprague Insurance Agency
6529 Crain Highway • La Plata, Maryland 20646

Phone: 301-934-6010
Phone: 301-934-6009
Toll Free #:1-800-619-6725

Hours: Monday – Friday: 9am - 5pm

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John L. Sprague Insurance Agency
Quote Submission Form for Auto and Home Quotes

*Name:	(required)
*Email Address:	(required)
*Phone Number:	(required)
Work Number:
Cell Number:
*Address:	(required)
*City, State, Zip:	(required)

Driver #1

Name:

Date of Birth:

Marital Status:

Single Married

Gender:

Male Female

Social Security #:

Drivers License State and Number:

Additional Drivers

Name: Relationship:

Gender: Male Female SS# DOB:

Drivers License State and Number:

Name: Relationship:

Gender: Male Female SS# DOB:

Drivers License State and Number:

Name: Relationship:

Gender: Male Female SS# DOB:

Drivers License State and Number:

Name: Relationship:

Gender: Male Female SS# DOB:

Drivers License State and Number:

Vehicle Information

Vehicle #1

Year: Make: Model:

VIN#: Usage: Work: Pleasure:

Vehicle #2

Year: Make: Model:

VIN#: Usage: Work: Pleasure:

Vehicle #3

Year: Make: Model:

VIN#: Usage: Work: Pleasure:

Vehicle #4

Year: Make: Model:

VIN#: Usage: Work: Pleasure:

Current Insurance Information

Present Carrier: Continuous Coverage For at Least 6 Months? Yes No

Is Your Current Bodily Injury Coverage $50,000/$100,000 or Higher? Yes No

Coverage Requested

Bodily Injury /Medical

Property Damage

Comprehensive

Collision

$25/50

$100/300

$250/500

$500/500

$20,000

$25,000

$50,000

$100,000

ACV

$100 ded

$250 ded

$500 ded

$250 ded

$500 ded

$1,000 ded

About Your Home

Owner Occupied

Condo

Renters

Landlord

No. Of Units

Living Sq. Footage Year Built

No. of Stories Garage (No. of Cars)

Attached Detached

Number of Bathrooms Number of Fireplaces

Roof Type Roof Age (Years)

Foundation

Rating Information

Fire Sprinkler Coverage

Fire Alarm Report

Prior Carrier

Number of Claims (Last 3 Years)

Insurance Information

Deductible

Please note any tickets or accidents with the dates and driver’s name in the Additional Comments section.

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