Inter-Ocean Insurance Agency
Car Insurance Quote Form
Customer Information
Island
*
St Croix
St Thomas / St John
Title
*
Mr.
Mrs.
Miss
Other
Full Name
*
First Name
Last Name
Date of Birth
*
Please select a month
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Month
Please select a day
1
2
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31
Day
Please select a year
2024
2023
2022
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1925
1924
1923
1922
1921
1920
Year
Marital Status
*
Single
Married
Divorced
Widow(er)
Occupation
*
Employer
*
Spouse Name
First Name
Last Name
Spouse Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
E-mail
*
example@example.com
Phone Number
*
Residential Address
*
Residential Address
Residential Address Line 2
City
State / Province
Postal / Zip Code
Use my Residential Address as my mailing address
Mailing Address
*
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Additional Drivers
Anyone under 25 in household?
*
Yes
No
Any additional drivers?
*
Yes
No
Driver 3
First Name
Last Name
Driver 3 Date of Birth
-
Month
-
Day
Year
Date
Driver 4
First Name
Last Name
Driver 4 Date of Birth
-
Month
-
Day
Year
Date
Driver 5
First Name
Last Name
Driver 5 Date of Birth
-
Month
-
Day
Year
Date
Driver 6
First Name
Last Name
Driver 6 Date of Birth
-
Month
-
Day
Year
Date
Underwriting Information
Do you currently have car insurance coverage?
Yes
No
Current Carrier
*
Any accidents/violations/auto insurance claims for any driver in the last 3 years?
*
Yes
No
Please list date and description of accident / violation / claim
Vehicle Information
*
Year
Make
Model
VIN
Mileage
Full Coverage?
Is Vehicle on Island?
Purchase Price (If New)
Auto 1
Auto 2
Auto 3
Auto 4
Auto 5
Auto 6
Would you like to take pictures of your vehicles?
*
Yes
No
Vehicle Pictures (Please take all 4 sides of each vehicle)
Browse Files
Cancel
of
Policy Coverage Options
Would you like to upload the Declarations Page for your current policy?
*
Yes
No
Declarations Page
Browse Files
Cancel
of
Bodily Injury Liability / Property Damage
10,000/20,000/10,000
10,000/20,000/15,000
25,000/50,000/25,000
Other
Medical Payments
1,000/5,000
Other
Accidental Death and Dismemberment
5,000
Other
Uninsured Motorists Liability
10,000/20,000
25,000/50,000
Other
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