Personal Auto Quote

Request an insurance quote for your personal automobile.

Click to open/close each section and enter required information. Time to complete: less than 5 minutes

Step # 1 of 8 - Personal and contact information

COMPLETE SECTION # 1 - PERSONAL INFORMATION

Your contact information will be kept private and secure.

What is your name: *

Home telephone number: *

Cell telephone number:

Work telephone number:

Email address:

What is the best way to contact you: *

When is the best time to contact you: *

S.S.N. (Optional):

Step # 2 of 8 - Current insurance information

COMPLETE STEP # 2 - CURRENT INSURANCE INFORMATION

Current insurance company: *

What is your current premium (optional):

What affects my premium

We may be able to find premium discounts based on some of the following: claim free; auto/home policies; multiple autos; good student; nonsmokers; and passive restraint.

How long have you been with your current insurance company: *

Current policy expiration date: *

Have there been any automobile claims filed in the past 5 years: *

Step # 3 of 8 - Protection for you

What is your comprehensive deductible: *

What is comprehensive coverage

Some of the coverages provided under comprehensive include theft, glass breakage, fire, windstorm, hail, water, falling objects, vandalism, explosion, or hitting a bird or animal. You may consider higher deductibles to lower your premiums.

What is your collision deductible: *

What is collision coverage

Collision covers damage to your car when your car hits, or is hit by, another vehicle, or other object. It pays to fix your vehicle less the deductible you choose. To keep your premiums low, select as large a deductible as you feel comfortable paying out of pocket.

Do you have towing coverage: *

Should I have towing coverage

When you have this coverage the insurer will pay reasonable expenses incurred for towing your car to the nearest place where necessary repairs can be made during regular business hours, towing your car out if it is stuck on or next to a public street or highway,etc.

Do you have rental car coverage: *

Do I need coverage for rental cars

Rental Reimbursement coverage provides a specified amount for you to rent a vehicle while your covered auto is being repaired or replaced after a loss covered under Comprehensive or Collision.

What are your current medical payment limits: *

How are medical payments handled

Medical Payments coverage provides coverage for necessary and reasonable medical and funeral expenses incurred as the result of an automobile accident.

What are your current uninsured/underinsured motorists limits: *

What happens if the other person doesn't have insurance?

Uninsured/underinsured Motorist coverage pays for bodily injury to you or your passengers involving a driver who has little or no liability coverage.

Step # 4 of 8 - Protection for other people

What are your current bodily injury & property damage damage limits: *

What do I want my policy to pay

This pays for bodily injury or property damage for which you become legally responsible due to an auto accident. For example, you were in an accident that was your fault and there was more than say $300,000 in damages, what is the amount you would want your policy to pay?

What are your current personal injury protection (PIP) payment limits: *

What is Personal Injury Protection?

PIP may cover the medical, hospital and funeral expenses of the named insured, others in his vehicles and pedestrians struck by him.

Step # 5 of 8 - Driver information

COMPLETE STEP # 5 - DRIVER INFORMATION

Driver # 1 name: *

Driver # 1 license number (Optional):

Driver # 1 age was this driver first licensed: *

Driver # 1 date of birth: *

Driver # 1 occupation: *

Driver # 1 relationship: *

Driver # 1 highest level of education this driver has completed: *

Driver # 1 current U.S. state license status: *

Driver # 1 gender: *

Driver # 1 marital status: *

Driver # 1 completed approved defensive driving course: *

Driver # 1 past 5 years has license been suspended or revoked: *

Driver # 1 full-time student: *

Driver # 1 require an SR-22 or Financial Responsibility Statement: *

Driver # 1 had any accidents in the past 5 years: *

Click here to enter information for driver # 2

Driver # 2 name:

Driver # 2 license number (Optional):

Driver # 2 age was this driver first licensed:

Driver # 2 date of birth:

Driver # 2 occupation:

Driver # 2 relationship:

Driver # 2 highest level of education this driver has completed:

Driver # 2 current U.S. state license status:

Driver # 2 gender:

Driver # 2 marital status:

Driver # 2 completed approved defensive driving course:

Driver # 2 past 5 years has license been suspended or revoked:

Driver # 2 full-time student:

Driver # 2 require an SR-22 or Financial Responsibility Statement:

Driver # 2 had any accidents in the past 5 years:

Click here to enter information for driver # 3

Driver # 3 name:

Driver # 3 license number (Optional):

Driver # 3 age was this driver first licensed:

Driver # 3 date of birth:

Driver # 3 occupation:

Driver # 3 relationship:

Driver # 3 highest level of education this driver has completed:

Driver # 3 current U.S. state license status:

Driver # 3 gender:

Driver # 3 marital status:

Driver # 3 completed approved defensive driving course:

Driver # 3 past 5 years has license been suspended or revoked:

Driver # 3 full-time student:

Driver # 3 require an SR-22 or Financial Responsibility Statement:

Driver # 3 had any accidents in the past 5 years:

Click here to enter information for driver # 4

COMPLETE STEP # 5 - DRIVER INFORMATION

Driver # 4 name:

Driver # 4 license number (Optional):

Driver # 4 age was this driver first licensed:

Driver # 4 date of birth:

Driver # 4 occupation:

Driver # 4 relationship:

Driver # 4 highest level of education this driver has completed:

Driver # 4 current U.S. state license status:

Driver # 4 gender:

Driver # 4 marital status:

Driver # 4 completed approved defensive driving course:

Driver # 4 past 5 years has license been suspended or revoked:

Driver # 4 full-time student:

Driver # 4 require an SR-22 or Financial Responsibility Statement:

Driver # 4 had any accidents in the past 5 years:

Step # 6 of 8 - Vehicle Information

Vehicle # 1 year: *

type

Vehicle # 1 make: *

type

Vehicle # 1 model: *

Vehicle # 1 Vehicle Identification Number (VIN): *

Vehicle # 1 annual mileage: *

Vehicle # 1 distance (one way) to work or school: *

Vehicle # 1 original vehicle cost: *

Vehicle # 1 kept at home address: *

Vehicle # 1 days driven to work or school: *

Vehicle # 1 ownership: *

Vehicle # 1 type of anti-theft device: *

Vehicle # 1 primary use: *

Vehicle # 1 registration: *

Click here to enter information for vehicle # 2

Vehicle # 2 year:

type

Vehicle # 2 make:

type

Vehicle # 2 model:

Vehicle # 2 Vehicle Identification Number (VIN):

Vehicle # 2 annual mileage:

Vehicle # 2 distance (one way) to work or school:

Vehicle # 2 original vehicle cost:

Vehicle # 2 kept at home address:

Vehicle # 2 days driven to work or school:

Vehicle # 2 ownership:

Vehicle # 2 type of anti-theft device:

Vehicle # 2 primary use:

Vehicle # 2 registration:

Click here to enter information for vehicle # 3

Vehicle # 3 year:

type

Vehicle # 3 make:

type

Vehicle # 3 model:

Vehicle # 3 Vehicle Identification Number (VIN):

Vehicle # 3 annual mileage:

Vehicle # 3 distance (one way) to work or school:

Vehicle # 3 original vehicle cost:

Vehicle # 3 kept at home address:

Vehicle # 3 days driven to work or school:

Vehicle # 3 ownership:

Vehicle # 3 type of anti-theft device:

Vehicle # 3 primary use:

Vehicle # 3 registration:

Click here to enter information for vehicle # 4

Vehicle # 4 year:

type

Vehicle # 4 make:

type

Vehicle # 4 model:

Vehicle # 4 Vehicle Identification Number (VIN):

Vehicle # 4 annual mileage:

Vehicle # 4 distance (one way) to work or school:

Vehicle # 4 original vehicle cost:

Vehicle # 4 kept at home address:

Vehicle # 4 days driven to work or school:

Vehicle # 4 ownership:

Vehicle # 4 type of anti-theft device:

Vehicle # 4 primary use:

Vehicle # 4 registration:

Step # 7 of 8 - Protection Review

In order to properly protect your assets, its important that we have complete information about your total account. Some of the questions determine if you are eligible for premium discounts.

COMPLETE SECTION # 7 - PROTECTION REVIEW

When does your home policy expire:

Who is your current company for homeowners insurance:

Provide information on the following:

	Yes	No	NA
Do you have a vacation home?
Do you have rental property?
Do you have household members away at school?
Is the property prone to flooding or located in a designated flood plain?
Is business or farming conducted on the property?
Do you have any income-producing hobbies?
Do you have any art, guns or collectibles?
Do you have jewelry that you would want replaced if it were lost or stolen while on vacation?
If you sewer backed up and your carpet was ruined, would you want it replaced?
In the event of death, would you want the mortgage on your home paid off?
Do you have an inventory of your household possessions?
Would you prefer to lower your premium by choosing a higher deductible?
Do you have any recreational vehicles such as boats or snowmobiles?
Do you have coverage for Identity Theft Restoration?
If you were sued for $1,000,000 or more because you were at fault in an auto accident, or someone got hurt on your property, would you expect your insurance to pay?
If you had a chronic illness that left you unable to care for yourself for an extended period or time, do you expect to be covered by insurance?

Step # 8 of 8 - Comments and approval

COMPLETE SECTION # 8 - COMMENTS & APPROVAL

Credit history: *

How did you hear about us: *

Comments and questions (optional):

Enter a short description that you can use for future reference (Optional):

This description will display in the file cabinet which contains your complete transaction history.

Customer name or code:

Thanks for providing this information . If we need to contact you for additional information, we will send you a message through the secure Message Center found in File Cabinet. You can view a copy of this request, and a copy of your ID card, by clicking on File Cabinet. You will receive an email confirming this request made on Tuesday, September 7, 2010 - 5:15pm. Your primary contact person in our office is .

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Personal Auto Quote