Save Money & Be Protected - Jim DiFalco Farm Bureau

Tell us about you!

Contact info
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Discounts

Help us save you money!
Are you current/retired military (including widowed spouses) or a member of any of these eligible professional associations?
Discount Question
Are you a part of any of these eligible civic associations?
Discount Question
Are you a university alumni member? Which university?
Would you be interested in our telematics program, which tracks your good driving and mileage to give you up to 40% discount!?
Are you currently with any of these companies, or have you been quoted by them recently? If so, and you provide us your declaration pages, we might have a discount for you!

Citizens/Hanover Auto Owners/Home Owners Frankenmuth Pioneer Hastings Fremont
Would you be interested in paying in full for 6 months or 1 year, to DRASTICALLY save money?! (Many of our customers pay with a card, get points/miles/cash back and vastly increase their savings and benefits!)

Yes No Show me both monthly and full pay options
Tell us what to insure!

Who and what can we protect for you!?
Drivers (Full Name & Date of Birth)
Tell us about each drivers commutes. (work/school?) (How far one way?)
Anyone have tickets or accidents in the last 36 months? (Describe)
Vehicles (Year, Make, Model & Loan/Lease/Owned)
Home/Condo/Apartment? (Own, Mortgage, Rent?)
Do you currently waive medical coverage on your auto insurance, using your health insurance provider instead?

Yes No I don't know
Would you like an umbrella quoted as well?

Yes No I don't know
Do you own a business? If so, would you like us to quote that to greatly increase your savings on BOTH your personal AND business policies?!

Yes No I do not own a business
Should be Empty:

Tell us about you!

Discounts

Tell us what to insure!