Garber Atlas Fries & Associates, Inc.

Insured Name*

Address

City

State/Province

Zip Code:

Phone:

E-mail:*

Do you presently have Auto Insurance?

YesNo

Company Name

Renewal Date

Annual Premium

Have you been cancelled or non-renewed in the past 3 years?

YesNo

Bodily Injury Liability

Property Damage Liability

Medical Payments

Uninsured Motorist Liability

Uninsured Motorist Property

Underinsured Motorist Liability

Underinsured Motorist Property

Comprehensive Deductible

Collision Deductible

Rental Reimbursement

YesNo

Towing & Labor

YesNo

1. (Primary Driver)

Please provide the names and birthdates of any other residents in your household licensed to drive.

* = Required Field

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.