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Defensive driving course information. 
Whether you have one car, or four – an RV or a motorcycle, let us compare plans and search for the best rates available.

We represent the most reputable and reliable insurance companies doing business in Texas. Our licensed agents are experienced in helping expedite processing of your claims.

Please remember, insurance cannot be placed into effect by completion of this information form. Insurance coverage is afforded only upon a written statement from the insurance carrier stating the terms, conditions and dollar amounts of insurance.
*Required information  
*Last Name:
*First Name:
*E-mail Address:
*Daytime Phone:
Home Phone:
Mobile Phone:
Fax:
Address:
*City:
*State:
*ZIP Code:
   
Other Details  
Have you had continuous coverage for at least 12 months?
Comments:  
Present Auto Insurance Company:  
Renewal Date:
Own Home?
   
Car #1      
Year: Miles to work (One Way):
Make: Annual Mileage:
Model    
2dr/4dr:    
Car #2      
Year: Miles to work (One Way):
Make: Annual Mileage:
Model:    
2dr/4dr:    
Car #3      
Year: Miles to work (One Way):
Make: Annual Mileage:
Model:    
2dr/4dr:    
 
Driver #1 Information
Driver Name:
Occupation:
Business:
Length at current job:
Highest level of education:
Date of birth:
Gender: Male Female
Driver's License No.:
Soc. Sec. No.:
Marital Status: Single Married Divorced
Number of Moving Violations in the past 3 years:
Comments:
Number of Accidents in the past 3 years:
Comments:
 
Driver #2 Information
Driver Name:
Occupation:
Business:
Length at current job:
Highest level of education:
Date of birth:
Gender: Male Female
Driver's License No.:
Soc. Sec. No.:
Marital Status: Single       Married       Divorced 
Number of Moving Violations in the past 3 years:
Comments:
Number of Accidents in the past 3 years:
Comments:
 
Driver #3 Information
Driver Name:
Occupation:
Business:
Length at current job:
Highest level of education:
Date of birth:
Gender: Male Female
Driver's License No.:
Soc. Sec. No.:
Marital Status: Single       Married       Divorced 
Number of Moving Violations in the past 3 years:
Comments:
Number of Accidents in the past 3 years:
Comments:
 
Liability Limit for All Cars
Bodily Injury Property Damage Single Limit
 25,000/50,000 25,000  60,000
50,000/100,000 50,000 100,000
100,000/300,000 100,000 300,000
250,00/500,000 500,000 500,000
 
Levels of current Uninsured Motorist coverage:
Car #1      
Deductable Comprehensive 100 250 500
Deductable Collision 250 500 1000
Tow Yes No  
Loss of Use Yes No
Car #2      
Deductable Comprehensive 100 250 500
Deductable Collision 250 500 1000
Tow Yes No  
Loss of Use Yes No  
Car #3      
Deductable Comprehensive 100 250 500
Deductable Collision 250 500 1000
Tow Yes No  
Loss of Use Yes No  
Do you use your auto or does anyone use your auto in any type of business of any time of activity to generate revenue, to make money, for delivery of shuttle or to assist in any type of business activity? Yes   No
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Frantzen Kaderli & Klier Insurance
108 Theodore Specht Drive
P.O. Box 513
Fredericksburg, Texas 78624

Hours: Weekdays, 8:00 a.m. to 5:00 p.m.
Excluding holidays

Phone: 830-997-9531
Toll Free: 1-800-280-9531

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