Kimberly Stamm
Broker / President
kstamm@dkrenterprises.com

7668 El Camino Real, Suite 104
Carlsbad, CA 92009

Phone: 800.331.3001
Fax: 877.260.7474

CA Lic# 0E34870
AZ Lic# 197233
OR Lic#685057
WA Lic# 757907

DKR & Associates is licensed to do business in the states of California, Arizona, Oregon and Washington.

Business & Commercial Auto Vehicle Insurance Quote

All information is required.
First and Last Name:  
Company Name:  
Address:  
City:  
State:  
Zip:  
Phone:  
E-mail:  
 

Vehicle Information
(List all cars you own/lease)
Vehicle 1:   Year Make/Model Vin #
Yearly Mileage Usage Alarm
Vehicle 2:   Year Make/Model Vin #
Yearly Mileage Usage Alarm
Vehicle 3:   Year Make/Model Vin #
Yearly Mileage Usage Alarm
Vehicle 4:   Year Make/Model Vin #
Yearly Mileage Usage Alarm
Any Custom equipment of vehicles? (if YES, give their value):  
 

Current Insurance Information
Insurance Company Name:  
Policy Exp. Date:   Premium Amt:  
Term:   How long with current?  
Debris hauled for others?:  
Trailer Hitch?:  
Liability Limit Requested:  
Class of Business:  
 

Driver 1
Name:   Sex:  
DL #:   Marital Status:  
Date of birth:   Driver's Education?:  
S.S.# (optional):   Defensive Driving:  
Years Licensed:   Good Student:  
Occupation:   SR 22 filing?:  

Driver 2
Name:   Sex:  
DL #:   Marital Status:  
Date of birth:   Driver's Education?:  
S.S.# (optional):   Defensive Driving:  
Years Licensed:   Good Student:  
Occupation:   SR 22 filing?:  

Driver 3
Name:   Sex:  
DL #:   Marital Status:  
Date of birth:   Driver's Education?:  
S.S.#(optional):   Defensive Driving:  
Years Licensed:   Good Student:  
Occupation:   SR 22 filing?:  

Driver 4
Name:   Sex:  
DL #:   Marital Status:  
Date of birth:   Driver's Education?:  
S.S.# (optional):   Defensive Driving:  
Years Licensed:   Good Student:  
Occupation:   SR 22 filing?:  

Accidents / Violations in the last 5 years?
Date Driver Violation Cost ($)
List any DUI convictions, license suspensions or revocations:  

Any additional comments or information that might be helpful in your quote:
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