Texas Community Insurance Group by Hoffman Financial Services, Inc.

Texas Community Insurance Group by Hoffman Financial Services, Inc. | Tel (972)758-9300 Fax (972)758-9355 | 1400 Preston Rd, Suite 345 Plano, Texas 75093

THE POWER OF PROTECTION972-758-9300

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Contact Information
Name:	Phone:
Mailing Address:	City:	State:	Zip:
Location Address:	City:	State:	Zip:
E-Mail:
If you have lived at the above address for less than 3 years, please provide your prior address below:.
Previous Address:	City:	State:	Zip:

Following forms are optional, Please fill in if you would like to provide more information.
Current Insurance Information
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

Vehicles
Car	Year	Make (eg. BMW, Ford, Mazda…)	Model (e.g., Civic, Taurus, Sentra ...)	VIN Vehicle Identification #
1
2
3
4

Car	Is car driven to work or school?	If "Yes", miles one way	If "Yes", Days per week	Is car used in business? (excluding to and from work)
1	Yes No			Yes No
2	Yes No			Yes No
3	Yes No			Yes No
4	Yes No			Yes No

Coverage Options
Bodily Injury	(per individual, per incident)
Property Damage
Medical Coverage
Combined Uninsured and Underinsured Motorists	(per individual, per incident)

Deductibles and Coverage Options
Car	Collision Deductible	Comprehensive Deductible	Rental Car	Towing (per incident)
1
2
3
4

Drivers
Driver	Name	Date of Birth (MM/DD/YYYY)	Sex	Marital Status	State Licensed
1			F M
2			F M
3			F M
4			F M

Comments, Questions, or Concerns

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

Thank You!

Contact Information