Personal Information

Name Spouse
Driver's License Number Driver's License Number
Address
City State     ZIP
Home Phone Work Phone
E-Mail Address Current Auto
Insurance Company
Renewal Date
(if known)
Own Home? Yes    No
Number of People in Household
Licensed Drivers in Household
Do you have medical coverage? Yes    No
Do you have disability coverage? Yes    No

Vehicles

# Year Make Model 2dr/4dr Miles to Work (1-way) Annual Mileage Comprehensive Deductible Broad Collision Deductible Towing / Labor Loss of Use?
1
  VIN#:
2
  VIN#:
3
  VIN#:
4
  VIN#:

Drivers

Insurance companies want to know about every licensed driver in the household.
If you have more than three, give the additional information on drivers in the comment section.

# Driver's Name Date of Birth Gender Marital Status Moving Violations
(last 3 yrs)
Accidents
(last 3 yrs)
1
2
3

Liability Limit for All Cars.

Choose either Bodily Injury & Property Damage or Single Limit
Bodily Injury Property Damage <- or -> Single Limit

Comments


Many people prefer to fax us a copy of their current policy deck sheets. Some send them as an e-mail attachment. If you wish, please do so. It makes our quote more accurate. Be sure to send both sides. Our 24-hour fax is (517) 546-9943. We also have group discounts. If you belong to an alumni group or you or your spouse is eligible to join one, let us know. Some other groups (often based on employment) offer discounts. Ask us if your group is included.

Please click on the Submit button to send your estimate request. This is not an application for insurance, and it does not obligate this agency to issue any policy of insurance.

Our estimate will include broad collision. Basic collision can save you premium dollars.