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Auto Quote
Auto Quote
First Name
Last Name
Middle Initial
Email Address
Do you own or rent your home?
Own
Rent
Other
Members in household:
Would you like us to include a quote for any of the following to receive a 10-25% multi-policy discount?
Home
Condo
Mobile Home
Renters
Life
Disability
Umbrella
Recreational Vehicles
Boats/Watercrafts
Antique/Classic Autos
Mopeds
Motorcycle
Prior Insurance
Are you currently insured?
Yes
No
Have you had continuous insurance for the past six months?
Yes
No
Current/Previous Insurance Carrier
Expiration Date
Driver Screen
First Name
Last Name
Gender
Male
Female
Select One
Occupation
Do you have health insurance?
Yes
No
Health Insurance Carrier*
What is the highest level of education completed?
Grade School
Associates Degree
Bachelor's Degree
Master's Degree
Doctorate
Select One
Would you like to add an additional driver?
Yes
No
First Name
Last Name
Gender
Select One
Male
Female
Occupation
Does the driver have health insurance?
Yes
No
Health insurance carrier
What is the highest level of education completed?
Grade School
Junior College
Bachelor's Degree
Master's Degree
Doctorate
Select One
Would you like to add an additional driver?
Yes
No
First Name
Last Name
Gender
Male
Female
Select One
Occupation
Does the driver have health insurance?
Yes
No
Health insurance carrier
What is the highest level of education completed?
Grade School
Junior College
Bachelor's Degree
Master's Degree
Doctorate
Select One
Would you like to add an additional driver?
Yes
No
First Name
Last Name
Gender
Male
Female
Select One
Occupation
Does the driver have health insurance?
Yes
No
Health insurance carrier
If driver is a student, ask if they have a 3.0 GPA or higher for an additional discount. Do any of the drivers qualify?
Main Driver
Additional Driver 1
Additional Driver 2
Additional Driver 3
Are any of the drivers attending college 100 miles or more away from home?
Main Driver
Additional Driver 1
Additional Driver 2
Additional Driver 3
Driving History
Does any driver have violations, suspensions, accidents, or claims (including glass claims, vandalism, and deer hits) in the past 5 years regardless of fault?
Yes
No
Incident Type
Violation
Suspension
Accident
Comprehensive Claim
Wreckless Driving
DWI
Accident at Fault
Glass Claim
Accident Not-At-Fault
Incident
1-10 mph
10-15 mph
15-20 mph
Careless Driving
Wreckless Driving
DWI
Accident At Fault
Glass Claim
Accident Not-At-Fault
Date of incidents
Amount of claim damage
Vehicle Information
Vehicle ID Number (VIN)
Car Year
Car Make
Car Model
Type
2 Door
4 Door
Truck
Select One
Is the vehicle paid, leased, or financed?
Select One
Paid
Leased
Financed
Use of vehicle
Pleasure
Work
0-3 miles
3-15 miles
15+ miles
Business
Safety Features
ABS
Air Bags
Security System
Would you like to add another vehicle?
Yes
No
Car Year
Car Make
Car Model
Type
Select One
2 Door
4 Door
Truck
Is the vehicle paid for, leased, or financed?
Select One
Paid
Leased
Financed
Use of vehicle
Pleasure
Work
0-3 miles
3-15 miles
15+ miles
Business
Safety Features
ABS
Air Bags
Security System
Policy Coverage
$100,000/$300,000
$250,000/$500,000
$1,000,000/$1,000,000
Select One
Property Damage
$250,000
$500,000
$1,000,000
Select One
Personal Injury Protection
Select One
Excess
Full
Uninsured/underinsured motorist liability
Comprehensive Deduction
$0
$100
$250
$500
$1000
Collision Deductible
$100
$250
$500
$1000
Basic
Limited
Towing Coverage
$50
$75
$100
$150
Rental Vehicle Coverage
20 day
30 day
40 day
50 day
* Required
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Contact Us:
Local: (810) 732-5800
Toll Free: (800) 530-9225
Fax: (810) 732-4154
G-3526 Miller Road
P.O. Box 321070
Flint, MI 48532