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40950 Woodward Ave., Ste 340, Bloomfield Hills, Mi 48304 | (248)549-3519
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PERSONAL INSURANCE
AUTO
HOME
CONDO
RENTER’S
MOTORCYCLE
ATV
BOAT or YACHT
COMMERCIAL INSURANCE
AUTO
LIABILITY and PROPERTY
INDIVIDUAL HEALTH, LIFE, DENTAL
LIFE INSURANCE
DENTAL
HEALTH
GROUP INSURANCE
GROUP HEALTH, LIFE, DENTAL
Customer Service
Personal Insurance Service
Commercial Insurance Service
Claim Reports
Payments
Film Producers
Search
Home
About Us
Contact Us
Get Quotes
PERSONAL INSURANCE
AUTO
HOME
CONDO
RENTER’S
MOTORCYCLE
ATV
BOAT or YACHT
COMMERCIAL INSURANCE
AUTO
LIABILITY and PROPERTY
INDIVIDUAL HEALTH, LIFE, DENTAL
LIFE INSURANCE
DENTAL
HEALTH
GROUP INSURANCE
GROUP HEALTH, LIFE, DENTAL
Customer Service
Personal Insurance Service
Commercial Insurance Service
Claim Reports
Payments
Film Producers
Search
~auto quote test
admin
2018-07-31T12:32:04-04:00
Please enable JavaScript in your browser to complete this form.
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Step
1
of 2
Desired Effective Date
*
Customer Type
*
Personal
Commercial
____________________________________________________________________________________
Insured Name
Marital Status
SSN:
Spouse Name
Spouse SSN:
Current Address, City ST ZIP
Phone
Checkboxes
Home
Cell/Mobile
Work
Email
*
Has insured moved within the last TWO YEARS?
*
Yes
No
Previous Address City, ST ZIP
Insured Birth Date
*
Occupation
(If retired indicate so)
Insured Education
High School Diploma (or GED)
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate
Why Do We Need This:
Total Number of Household Members
(include DRIVERS and NON-DRIVERS)
Spouse?
Yes
No
Spouse Name
Spouse Birth Date
Spouse Occupation
Spuose Education
High School (or GED)
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate
Group Membership? (Alumni, AARP, etc.)
Enter the name of your group or for a List of groups
CLICK HERE
If you find a group that applies, enter the name here.
CURRENT INSURANCE
Do you currently have Auto Insurance?
*
Yes
No
If NO current insurance, is this
New Purchase
Currently Un-Insured
Current Policy Number
Current Insurance Company Name
Current Insurance Expiration Date
Has Your Insurance Ever Been Cancelled or Non-Renewed?
*
Yes
No
If Yes, please explain why
DRIVER INFORMATION
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Driver Name #1 (or Insured)
*
(use "SAME" if same as Name above.)
Driver's License Number #1 (or Insured)
*
License State #1 (or Insured)
*
Birth Date#1 (or Insured)
*
(use "SAME" if same as above.)
Driver Gender #1 (or Insured)
*
Female
Male
Driver Name (Spouse)
(use "SAME" if same as Spouse Name above.)
Driver's License Number (Spouse)
License State (Spouse)
Birth Date (Spouse)
Driver Gender (Spouse)
Female
Male
Number of Additional Drivers
*
0
1
2
3
4
(if more drivers, please put additional driver information in "NOTES" field)
For Additional Drivers we
MUST
have the following information for each:
1. Name
2. Birthdate xx/xx/xxxx
3. License State
4. License Number
5. Gender
6. Marital Status
7. Relationship to Insured
Additonal Driver 1
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 2
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 3
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 4
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Tickets and Accidents in the last THREE YEARS. (Do not include towing or windshield claims)
We
MUST
have the following information for each:
1. For Both - Driver Name
2. For Both - Incident Date xx/xx/xxxx
3. For Accident - Description
4. For Accident - Insured Driver at Fault (Y or N)
5. For Accident - Amount Paid
6. For Ticket - Type of Ticket Issued
Tickets and/or Accidents, All Drivers
Briefly DESCRIBE any TICKETS or ACCIDENTS in the Last THREE YEARS. Include DRIVER NAME approximate DATE and amount paid for all claims except Towing or Glass.
VEHICLES AND USAGE
Number of Vehicles
*
1
2
3
4
5
6
(if more than FOUR additional drivers please call)
Vehicle 1 Driver Name
*
Vehicle 1 Year, Make, Model and VIN#
*
(VIN # = Vehicle Id Number)
Vehicle Use 1
*
Pleasure
Commercial (incl delivery)
To Work or School
Service
Other
Work Use (in course of employment)
Miles to Work or School (One Way)
If "Other" Use - describe 1
Estimated Annual Miles Vehicle 1
*
VEHICLE 2
Vehicle 2 Driver Name
Vehicle 2 Year, Make, Model and VIN#
(VIN # = Vehicle Id Number)
Vehicle Use 2
Pleasure
Commercial (incl delivery)
To Work or School
Service
Other
Work Use (in course of employment)
Estimated Annual Miles Vehicle 2
VEHICLE 3
Single Line Text
Multiple Choice
First Choice
Second Choice
Third Choice
Numbers
VEHICLE 4
Single Line Text
Multiple Choice
First Choice
Second Choice
Third Choice
Numbers
VEHICLE 5
Single Line Text
Multiple Choice
First Choice
Second Choice
Third Choice
Numbers
VEHICLE 6
Single Line Text
Vehicle Use 6
Pleasure
Commercial (incl delivery)
To Work or School
Service
Other
Work Use
Estimated Annual Miles Vehicle 6
PHYSICAL DAMAGE COVERAGE
Any Vehicles on a Stated Amount Basis?
Yes
No
What is this?
Comprehensive Coverage
Yes
No
What is this?
Comprehensive Deductible
$100
$250
$500
$1,000
$2,500
Collision Coverage
Yes
No
Type of Collision
Broadened
Regular
Limited
What is this?
Collision Deductible
$100
$250
$500
$1,000
$2,500
LIABILITY COVERAGE
LIABILITY Coverage Same as Other Vehicles
Yes
No
Dropdown
100,000 / 100,000
100,000 / 300,000
250,000 / 500,000
300,000 / 300,000
500,000 / 500,000
500,000 / 1,000,000
1,000,000 / 1,000,000
DRIVER INFORMATION
New or Existing Driver
Existing
New
Existing Driver Name
New Driver Name
Drivers License #
Birth Date
Relationship to Insured
Tickets or Accidents
Yes
No
Tickets or Accidents in Last 3 Years
Please list a description of any accidents, approximate date of accidents/tickets and type of ticket issued. If Not At Fault, please indicate so.
FINANCING
Vehicle Financed
*
Yes
No
Type of Financing
Lease
Loan
Vehicle Lessor or Leinholder Name and Address
If available, do you want Lease/Loan Gap coverage?
Yes
No
Next
VEHICLE CERTIFICATE
Send No-Fault Verification to
*
Insured
Car Dealer or Other
Not Needed at this time
Delivery Method - Dealer / Other
E-Mail
Fax
US Post
Name - Dealer / Other
Phone - Dealer / Other
E-Mail - Dealer / Other
Fax - Dealer / Other
Address - Dealer / Other
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Certificate Needed No Later Than
*
Date
Time
(if needed IMMEDIATELY please let us know)
NOTES / COMMENTS
Name of Person Completing for if Not Same as Above
*
Confirmation Email
*
(We need this to sent your a confirmation receipt for this form.)
Captcha
*
=
('*' = Multiply, '+' = Add, '-' = Subtract)
Checkboxes
First Choice
Second Choice
Third Choice
Multiple Choice
First Choice
Second Choice
Third Choice
Single Line Text
Any Drivers Away at School more than 50 miles? If so list names here
Comments
Single Line Text
Dropdown
First Choice
Second Choice
Third Choice
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