Your full name:    
Your occupation & employer
Spouse occupation/employer:
Your email address:              
Your home phone number:    
Your work phone number:    
Your home street address:    
Your city:                             , State

Is the state you chose Indiana?   If not, DO NOT GO FURTHER.  THIS PAGE FOR INDIANA QUOTES ONLY!
Your ZIP Code:                   
Number of People in House:

Choose One: Own Mobile Home<10 yrs old;   Own Home; Rent;  Live w Parents; Other
What company insures your home/personal property?

We can likely save you the most money by packaging your auto insurance with either a homeowners policy or a renters policy with our special "Multi-Policy" discounts!!  When you are done here, grab that policy and go to our homeowners quote page.  There is a link at the end of this input.

Medical Ins. Company or NONE:   
Disability Ins. Company or NONE:   If you have a disability plan through work that would pay your lost income if you couldn't work due to auto accident injuries.

Do you have Auto Ins in force now?  IF NOT, STOP HERE AND CALL US FOR QUOTE.
If so, Current Auto Ins. Co.:             
Policy Number:                               There will be no response to your request if not included.
Expiration Date:                               
Current 6 mo premium                     

Are you being cancelled by your current company?  If so, WHY?
Are you a member of a group (AARP, Alumni Assoc. etc.) 

HOUSEHOLD INFO: List info on ALL household members including yourself(even if they don't drive) AND any other drivers

Household Member # 1 (Full name including full middle name--even if you already put it above)

Name

Birthdate Married   or Single          Male     or  Female

Social Security Number  Note: Some companies give a discount that depends on credit rating. Thus, a credit report will be ordered to determine if you are eligible for a discount. We do not ever see the credit report.  The company's computer looks it ups and we are told whether or not you qualify for the discount without any other information on your credit report. If you are adamant about NOT wanting to have a credit report search, then please state so in the comments at the end of this form prior to submitting.  You will not be eligible for the discount in this case and your quote may be higher than otherwise:

 

Has this driver had any ticket/accident in last 5 years? (Y or N)
    

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Household Member # 2 (Full name including full middle name)

Name

Birthdate   Married   or Single      Male     or  Female

 

Had any ticket/accident in last 5 years? (Y or N) 
    

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Household Member # 3 (Full name including full middle name)

Name

Birthdate    Married   or Single      Male     or  Female

 

Had any ticket/accident in last 5 years? (Y or N) 
   

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Household Member # 4 (Full name including full middle name)

Name

Birthdate   Married   or Single      Male     or  Female

 

Had any ticket/accident in last 5 years? (Y or N) 
    

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Household Member # 5 (Full name including full middle name)

Name

Birthdate   Married   or Single      Male     or  Female

 

Had any ticket/accident in last 5 years? (Y or N)     

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Are there any more household members? Yes;   No  If so, please list their info at the end in "Other Comments"

 

TICKETS AND/OR ACCIDENTS IN LAST 5 YEARS FOR ALL HOUSEHOLD MEMBERS AND DRIVERS; PLEASE LIST DETAILS     

Please give all details on any tickets or accidents for all members of the household during the last 5 years. Be sure to include 1) name of driver, 2) date of occurance, 3) description of occurance, and 4) amount of claim if applicable.  If there have been absolutely none, please state "None"
 

 

CLAIM DETAILS IN LAST 5 YEARS.  Please describe all claims you have had in the last 5 years including deer, windshield, theft, accidents(including "not at fault"), etc..  Provide details, dates, and amounts paid for the claim.  If there have been absolutely none, please state "None"

(You can keep typing past the end of the box)

 

  AUTO INFORMATION    
Car1

Bodily Injury Liability Limits

Please choose a liability limit from the limits listed below. Limits are per person/per occurance. Limits will be the same for all vehicles.  This covers you if you injure someone and they sue you. With law suits the way they are today, we recommend the highest limits possible and we also recommend that you obtain an umbrella policy to "blanket" over your home and auto insurance.  Ask us about it.

Property Damage Liability Limits:

Please choose a property damage liability limit from the list below. Limits will be the same for all vehicles. This covers you if you damage someone's property (ie parked car, house, etc.) and they sue you.
$50,000 $100,000 $250,000 $500,000      

                
Medical Payments

Please choose the Medical Payments coverage limit you would like from the list below:

Enter your Medical choice     $10,000 $5,000 $2,000 $1,000 NONE WANTED  

Do you wish to have your Medical Payment coverage be Excess of other coverage? Yes No

.     
Specific Car Coverages:

Good Student Discount Note: If any of the drivers is a full time student and on the honor roll/dean's list, please let us know in the extra comments section.  You may be eligible for a "Good Student Discount"

Extra comments; enter additional household member info, additional autos, good student info, etc.:

 Did you fill in all the information?  Did you have your existing policy in front of you to ensure "apples-to-apples"?

How did you find our site?  Yahoo Other Search Engine Referral From a Friend/Relative Ad in Wall St. Journal Radio Ad Television Ad Received Info in Mail Other

If you entered Other Search Engine, which one? or if you entered "Other", where?

Did you find our quote form easy to use?  Put any ideas for improvements here:

Thank you for completing our online quote form. Please let us know how you would like us to send you the quote:

 Phone Call     Fax  

If you entered "phone call" and we call at night, how late can we call you?

If you entered "Fax", what is your fax number: