Full Name:          
Mailing Address:
City:
Florida
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
Current Insurance Company: 
Expiration Date: (mm/dd/yyyy)
Current Auto Insurance Policy Liability Limit:

Florida Auto Insurance Coverage Information:

Vehicle     Year             Make                Model                Body Type
     1        
     2        
     3        

Pickup Truck Information (if applicable):
Does your truck have a cap?
If Yes, what is its value: $

Vehicle     Primary Use     Miles Driven to Work
     1               
     2               
     3               

Additonal Auto Insurance Information:

                                                         Garaged          Lienholder        Lienholder
Vehicle              VIN#                      Zip Code          Yes/No               Name
     1          
     2          
     3          

Florida Auto Insurance Coverage Information:

                      Liability                 Property                   Uninsured
Vehicle    Limits(x $1,000)          Damage             Motorist(x $1,000)       Medical
     1                                     
     2             SAME                       SAME                       SAME                   SAME
     3             SAME                       SAME                       SAME                   SAME


                   Collision         Comprehensive
Vehicle    Deductible           Deductible
     1             
     2             
     3             

Endorsements
Vehicle      Towing                   Rental
     1              
     2              
     3              

Florida Driver Information:

                                  Drivers                     Date of                                       Drivers
Driver                       Name                          Birth               Gender             License #
     1                   
     2                   
     3                   


                           Drivers                  How Long          Marital                  Social
Driver             Occupation                Licensed            Status                  Security #
     1                   
     2                   
     3                   

Is your driving record accident & violation free during the past 5 years?
Driver
     1         If No, how many accidents?    How many violations? 
     2         If No, how many accidents?    How many violations? 
     3         If No, how many accidents?    How many violations? 

Was your driver's license suspended during the past 5 years?
Driver
     1      
     2      
     3      

Additional Information or Comments


Click on the "Submit Quote Request" button below to
send your Florida Auto insurance quote request.**


**Information received from this Florida Auto Insurance quote request form
sent to Optimal Insurance Group will be for our use only and will not be
sold, given to or distributed to any other parties. A quote will be based
on the Florida auto insurance policy information provided and does not
guarantee acceptance of the risk by us. The precise coverage
afforded is subject to meeting underwriting guidelines, and the terms,
conditions and exclusions of the policy as issued. By submitting this
request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle you to a
Florida Auto Insurance policy. We are licensed in Florida and will not
provide auto insurance quotes for other states.


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Optimal Insurance
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FL offers affordable
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throughout south
Florida.
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Health, Auto, Renters,
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at (561) 342-1695.
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We are an independent Boca Raton, Florida insurance agency offering
cheaper auto insurance policy premium quotes in the following towns,
cities and counties in south Florida: Boynton Beach, Gulf Stream, Delray
Beach, Lantana, Rainbow Lakes, Atlantis, Lake Worth, South Palm
Beach, Palm Springs, Greenacres, Wellington, Haverhill, Palm Beach,
Golden Lakes, Riviera Beach, Glen Ridge, West Palm Beach, Lake Park,
Royal Palm Beach, Jupiter, Coral Springs, Fort Lauderdale, Parkland,
Coconut Creek, Margate, North Lauderdale, Lighthouse Point, Hillsboro
Beach, Deerfield Beach, The Hamptons, Highland Beach, Weston,
Plantation, Playland Isles, Melrose Park, Lauderhill, Sunrise, Tamarac,
Wilton Manors, Oakland Park, Lauderdale Lakes, Sea Ranch Lakes,
Villages of Oriole, Pompano Beach, Lauderdale-by-the-Sea, Boca West,
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Palm Beach Shores, South Miami, Cutler Ridge, Princeton, Perrine,
Naranja, Homestead, Florida City, Leisure City, Richmond Heights,
Pinecrest, Howard, Coral Way Village, Westchester, Westwood Lakes,
Brownsville, Sweetwater, Key Biscayne, North Bay Village, Miami Beach,
Miami Springs, Virginia Gardens, Hialeah, El Portal, Miami Shores,
Medley, Indian Creek, Surfside, Bal Harbour, North Miami, Biscayne Park,
Pinewood Park, Opa Locka, Bunche Park, Hialeah Gardens, Palm Springs
North, Carol City, Norland, Ojus, Miami Lakes, Biscayne Gardens,
Hallandale, Sunny Isles Beach, Golden Beach, Aventura, Uleta, Miramar,
Pembroke Pines, North Miami Beach, Hallandale Beach, Ives Estates,
Pembroke Park, Coral Gables, Kendall, Dania Beach, Cooper City, Davie,
West Miami, Hollywood, Broward County, Martin County, Miami-Dade
County, and Palm Beach County, FL.
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Optimal Insurance Group
4800 North Federal Hwy
Suite D-100
Boca Raton, Florida 33431
Palm Beach County FL
(561) 342-1695
Fax: 866-314-4026
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