SR-22 Filing - Klump Insurance Agency, LTD. of Missouri



Klump Insurance Agency, LTD.
"We do the shopping for you"

2864 Sugartree Lane
Maryland Heights, MO 63043
314-739-1346
314-739-1360 (fax)
E-mail:JeffKlump@SBCGLOBAL.NET
Our agency is licensed to quote and write insurance policies only in Missouri. To find agents offering these coverage in all of the other states, please click the IQ.net logo.

SR-22 Auto Insurance Quote

An SR-22 filing is a legal filing between the state of Missouri, in particular, the Department of Revenue and an insurance company. This filing is a monitoring device for the state to make sure an individual maintains insurance for the time that the state requires.

An SR-22 filing is required when your drivers license is suspended or
revoked, due to :

too many moving violations within an 18 month period
an alcohol related citation, i.e. DWI, DUI, chemical refusal, Blood Alcohol level over the legal limit
being involved in an accident while uninsurance

Note : Most of the large insurance companies i.e. State Farm, Allstate, American Family and GEICO, normally will not file an SR-22 because it is considered a high-risk situation.

Complete this form and submit it to our agency to receive an accurate quote.

General Information

Name: (required)

E-Mail Address: (required)

Street:

City: (required)

County:

State:(required) Zip: (required)

Day Phone:

Evening Phone:

FAX:

Please list your family's drivers by first name, sex and birthdate.

Drivers Names
Gender

Date of Birth
(required)

Social Security Number
(suggested)

# 1

# 2

# 3

# 4

In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information.

Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name

Do you own/buying your home? Yes No

Major Credit Card? Yes No

We need to know about your cars.
Please provide the year, make, model & name of daily driver
Answer should look like this : 1998, Ford, Taurus, Mary

All of this information is required to receive a quotation

Veh# How is this car used?
Annual Miles

1

2

3



The following information is optional, but highly suggested and if given we will be able to provide you with a more accurate premium quotation.

Drivers License Number (Suggested)
Vehicle Identification Numbers (Suggested)

1 Veh # 1

2 Veh # 2

3 Veh # 3

4

Tell us the current coverages on your cars?

Comprehensive Deductible

Collision Deductible

Bodily Injury Liability Limit (000)

Property Damage Liability Limit

Uninsured Motorist Bodily Injury Liability (000)

Uninsured Motorist Property Damage Liability

Personal Injury Protection

Medical Payments

Road Service Coverage

Rental Car Reimbursement

What month current policy expire?

What is the name current insurance company?

Accidents & Violations

Last 3 Yrs (Minors)
Last 5 Yrs (Majors) Driver 1 Driver 2 Driver 3 Driver 4

Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)

Accidents - Non Chargeable (Within the last 5 years)

Accidents - Chargeable (Within the last 5 years)

Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit (Within the last 5 years)

Please use this area to give us any additional information that you may feel is important for your insurance. ie: Is one of your cars used to deliver pizzas or conduct another type of business? Do your young drivers have a B average or better in school?

Are there any additional cars or drivers?

General Information
Name: (required)
E-Mail Address: (required)
Street:
City: (required)
County:
State:(required)	Zip: (required)
Day Phone:
Evening Phone:
FAX:

Tell us the current coverages on your cars?
Comprehensive Deductible
Collision Deductible
Bodily Injury Liability Limit (000)
Property Damage Liability Limit
Uninsured Motorist Bodily Injury Liability (000)
Uninsured Motorist Property Damage Liability
Personal Injury Protection
Medical Payments
Road Service Coverage
Rental Car Reimbursement
What month current policy expire?
What is the name current insurance company?

This page and site has been developed and maintained by InsuranceQuote.Net

mail to: gkh@InsuranceQuote.net

Page Created 2-15-02

Latest Revision

Drivers Names	Gender	Date of Birth (required)	Social Security Number (suggested)
# 1
# 2
# 3
# 4
In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information.
Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name
Do you own/buying your home? Yes No
Major Credit Card? Yes No


Drivers License Number (Suggested)		Vehicle Identification Numbers (Suggested)
1	Veh # 1
2	Veh # 2
3	Veh # 3
4

Accidents & Violations
Last 3 Yrs (Minors) Last 5 Yrs (Majors)	Driver 1	Driver 2	Driver 3	Driver 4
Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)
Accidents - Non Chargeable (Within the last 5 years)
Accidents - Chargeable (Within the last 5 years)
Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit (Within the last 5 years)

We need to know about your cars.
Please provide the year, make, model & name of daily driver
*Answer should look like this* : 1998, Ford, Taurus, Mary

**All of this information is required to receive a quotation**
Veh#	How is this car used?	Annual Miles
1
2
3

General Information

Tell us the current coverages on your cars?

Accidents & Violations