Mechanical Breakdown and
Warranty Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Name:
Property Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):
 
Underwriting Information
 
Year, Make, and Model
of Your Vehicle?:
 
Original Date of Purchase (MO/YR)?:
 
Number of months left on current vehicle warranty?:
 
Current Vehicle Odometer (mileage) Reading:
 

 

Coverages (warranty time):
 
If Vehicle is New:
Select Coverage at Right (for NEW vehicles ONLY): 5 year/80,000 miles
5 year/100,000 miles
6 year/60,000 miles
6 year/80,000 miles
6 year/100,000 miles
7 year/100,000 miles
 
If Vehicle is USED:
Select Coverage at Right (for NEW vehicles ONLY): 3 year/36,000 miles
(Vehicle MUST have less than 65,000 to qualify)

3 year/36,000 miles
(Vehicle MUST have less than 70,000 to qualify)

1 year/12,000 miles
(Vehicle MUST have less than 90,000 to qualify)
 
Comments/Remarks:
 
Send my quotation via: E-Mail Fax
Regular Mail

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow Basic West Insurance Agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

 

Yes, I Agree. Please Send Me a Quote NOW!