Flamingo Insurance Agency

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Flamingo Insurance Agency
Flamingo Insurance
Hialeah Office
2189 West 60 Street
Suite 202
Hialeah, Fl 33016
305-828-4847

Coral Gables Office
124 Madeira Avenue
Coral Gables, FL
305-448-2887

Toll Free
1-888-839-7383

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Automobile Insurance Quote Form

Customer Information
Customer Name*
Location Address
City
State
Zip Code
Home Phone*
Alternate Phone
Email *
Driver Information

DRIVER 1
Name

Date of Birth
Sex
Marital Status
Social Security
Month
Day
Year
Relation to Insured
Occupation
Tickets/Claims
Years
Licensed
Driver's License No.
 

DRIVER 2
Name

Date of Birth
Sex
Marital Status
Social Security
Month
Day
Year
Relation to Insured
Occupation
Tickets/Claims
Years
Licensed
Driver's License No.
 

DRIVER 3
Name

Date of Birth
Sex
Marital Status
Social Security
Month
Day
Year
Relation to Insured
Occupation
Tickets/Claims
Years
Licensed
Driver's License No.
 

DRIVER 4
Name

Date of Birth
Sex
Marital Status
Social Security
Month
Day
Year
Relation to Insured
Occupation
Tickets/Claims
Years
Licensed
Driver's License No.
 

DRIVER 5
Name

Date of Birth
Sex
Marital Status
Social Security
Month
Day
Year
Relation to Insured
Occupation
Tickets/Claims
Years
Licensed
Driver's License No.
 
Vehicle Information
 
Year
Make
Model
VIN #
Air
ABS
H/O
Alarm
Miles
Use
1.
Personal
2.
Personal
3.
Personal
4.
Personal
5.
Personal
Prior Insurance
Prior Company
Expire Date
Coverage & Limits
Was there a lapse in coverage?
Yes
Yes
Yes
 
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