info@kalerco.com, kalerInsuranceLLc@gmail.com
408-205-5695, 408-300-5930
Kaler Insurance Agency LLC ( Working Remotely)
CA. License: 0L90210
6203 San Ignacio Ave #110,
San Jose
CA
95119
Home
Contact Us
Auto Insurance Form
Personnal Information
Full Name
Date of Birth
Phone
Email
State
--Select--
Howland Island
Delaware
Alaska
Maryland
Baker Island
Kingman Reef
New Hampshire
Wake Island
Kansas
Texas
Nebraska
Vermont
Jarvis Island
Hawaii
Guam
United States Virgin Islands
Utah
Oregon
California
New Jersey
North Dakota
Kentucky
Minnesota
Oklahoma
Pennsylvania
New Mexico
American Samoa
Illinois
Michigan
Virginia
Johnston Atoll
West Virginia
Mississippi
Northern Mariana Islands
United States Minor Outlying Islands
Massachusetts
Arizona
Connecticut
Florida
District of Columbia
Midway Atoll
Navassa Island
Indiana
Wisconsin
Wyoming
South Carolina
Arkansas
South Dakota
Montana
North Carolina
Palmyra Atoll
Puerto Rico
Colorado
Missouri
New York
Maine
Tennessee
Georgia
Alabama
Louisiana
Nevada
Iowa
Idaho
Rhode Island
Washington
Ohio
Others
Zip Code
Auto Details:
Year
--Select--
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
Pre-1981
Make
--Select--
AC
Acura
Alpina
Ariel
Aston Martin
Audi
Avanti
Bentley
Bizzarrini
BMW
Bugatti
Buick
Cadillac
Chevrolet
Chrysler
De Tomaso
Dodge
Eagle
Ferrari
Ford
GMC
Honda
Hummer
Hyundai
Infiniti
Isuzu
Jaguar
Jeep
Kia
Koenigsegg
Lamborghini
Land Rover
Lexus
Lincoln
Lotus
Maserati
Maybach
Mazda
MCC
McLaren
Mercedes-Benz
Mercury
Mini
Mitsubishi
Morgan
Nissan
Noble
Oldsmobile
Pagani
Panoz
Pontiac
Porsche
Rolls-Royce
Saab
Saleen
Saturn
Scion
Smart
Spyker
Subaru
Suzuki
Toyota
Vector
Volkswagen
Volvo
Model
Vehicle Number:
Vehicle Ownership Duration?
--Select--
Less then 1 Month
1 Month to 1 Year
1 Year to 3 Year
Primary use?
--Select--
Personal
Ridesharing
Business
Commercial
Farming
Primary Address
Loan or Lease ?
--Select--
Own
Loan Payment
Lease
Make value
Advanced Driver Assistance System:
Does vehicle have automatic emergency brake technology?
Yes
No
Does vehicle have blind spot technology?
Yes
No
Driving Details:
Gender
Marital Status
--Select--
Single
Married
Separated
Divorced
Widowed
Domestic Partner
License Status:
--Select--
Active
Permit
Suspended
Permanently Revoked
Expired
Not Licenced
Commercial/Business
Foreign Licenced
Driving Experience
Driver Licence Number
Accidents, Violations, and Claims:
Do you have an auto policy?
Yes
No
Any Accidents as a Driver?
Yes
No
Tickets or Violations?
Yes
No
Any Accidents as a Driver?
Yes
No
Additional Information:
Additional vehicle or driver informations?:
Vehicle Number:
Submit
