AUTO INSURANCE When you buy auto insurance, you're not just protecting your vehicle, you're protecting your way of life. Automobile insurance premiums are based on a large number of factors, some of which you can control and others that you cannot. Overwhelmed? It can be more than a bit confusing when trying to decide the best and most affordable coverage for your vehicle. That's why we're here. Please fill out the form below as accurately as possible for the best rate.   GET A QUOTE NOW! 1. Do you currently have auto insurance? Yes No 2. What is the name of your current auto insurer? Select One Company Not Listed AAA Aetna Allied Allstate American Family American National Amica Atlanta Casualty Auto Owners CNA Dairyland Erie Farm Bureau Farmers Geico Guaranty National Horace Mann Liberty Mutual Metropolitan MidCentury (Farmers) MidWest Mutual Millers Mutual MSI Mutual of Omaha Nationwide Pafco Pemco Preferred Risk Primerica Progressive Prudential Safeco Sentry Shelter State Farm USAA USF&G Viking Western National If not listed, please give company name: 3. Current liability limit: Select One State Minimum $50,000/$100,000 $100,000/$300,000 Not Sure 4. How many years have you had auto insurance with this company? 5. How many years have you continuously had auto insurance? 6. When does your policy renew? Select One 1-3 months 4-7 months 8-14 months Not sure 7. How much do you currently pay for your insurance? $ 8. How often do you pay that premium? Select One Monthly Quarterly Every six months Annually 9. When would you like your new policy to take effect? Select One Immediately 15 days 30 days Other 10. Number of drivers? Select One One Two Three Four Five Other DRIVER INFORMATION 11. Name on Driver's License (Last, First, MI): 12. Driver's License Number: 13. Social Security Number: 14. Date of Birth: 15. Sex: Male Female 16. Marital Status: Select One Single Single parent Married Separated Divorced Widowed 17. State of Issue: 18. Highest Grade Level: Select One None or Incomplete High School Diploma GED Some college College degree Masters degree PhD 19. Occupation: 20. Years Licensed: DRIVING HISTORY 21. Any DUI or DWI in the last 5 years? Yes No 22. Has your license been suspended in the last 5 years? Yes No 23. Has your license been revoked in the last 5 years? Yes No 24. Do you require a SR-22? Yes No 25. Number of moving violations in the last 4 years? (Speeding, Stop Sign, Etc.) Select One One Two Three Four Five or more Not sure 26. Number of accidents in the last 4 years? Select One One Two Three Four Five or more Not sure 27. Total Points received in the last 4 years? Select One One Two Three Four Five or more Not sure 28. Total Fines received in the last 4 years? Select One One Two Three Four Five or more Not sure 29 . Please detail ALL Violation (tickets) in the last 4 years for primary driver. Include all dates of the violations. 30. Secondary Drivers (Please list all the drivers.) VEHICLE INFORMATION 31. Year: 32. Make: 33. Model: 34. Type: Select One Coupe Sedan SUV Convertible Minivan Truck Motorcycle Commercial Van Other 35. VIN: 36. Number of Doors: Select One 4-dr 2-dr Truck Van 37. Fuel? Select One Gas Diesel Electric 38. Cylinders? Select One 1 2 3 4 5 6 7 8 9 10 11 12 39. Turbo/Supercharged? Yes No 40. 4-Wheel Drive? Yes No 41. Anti-Lock Brakes (ABS)? Yes No 42. Alarm Type? Select One No alarm Audible Alarm Lojack On Star Teletrac Other 43. Number of Air Bags? Select One One Two Three Four Other 44. Seat Belts? Select One Lap Only Lap & Chest Auto Seat Belts 45. Parking: Select One Street Parking Lot Secure Garage Carport Other 46. Zip of Parking: 47. Leased: Lease Own 48. Auto Use: Select One Commute To/From Work Commute To/From School Pleasure Business (Individual) Government Farm Other 49. Miles to Work (1 Way): Select One 1-5 6-10 11-15 16-20 20+ Business Use 50. Days in Use: Select One 1 2 3 4 5 6 7 51. Annual Miles: Select One 0-5000 5001-10000 10001 15000 15001-20000 20000+ 52. Comprehensive Deductible: Select One No Coverage $100 $250 $500 $1000 Other 53. Collision Deductible: Select One No Coverage $100 $250 $500 $1000 Other 54 . Please list all other vehicles you would like us to consider: TYPE OF AUTO COVERAGE 55. Bodily Injury: Select One State Minimum $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Other 56. Property Damage Limit: Select One State Minimum $15,000 $25,000 $50,000 $100,000 Other 57. Uninsured Motorist Coverage: Select One State Minimum $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Other 58. Please indicate which features you would like: Medical Coverage Yes No Towing Coverage Yes No Rental Car Reimbursement Yes No Glass Coverage Yes No GENERAL INFORMATION First Name: Last Name: Phone: E-mail: Street Address: City: State: Zip Code: County: Best time to contact: Please provide any additional information that may affect your quote. Thank you for filling out our form! We will respond promptly.

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