Auto Insurance Quote
Complete the required fields and a representative will contact you. However, the more fields you fill out, the more accurate your quote will be.
Primary Driver - Full Legal Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*Select all that apply*: Type of Vehicle Insurance
Car Insurance
Motorcycle, Sport Bike, Cruiser, etc Insurance
RV or Motorhome Insurance
Golf Cart Insurance
Other
Date of birth
*
-
Month
-
Day
Year
Date
Do you own or rent the house you live in?
*
Rent
Own
Highest level of education
*
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
Drivers License State and Drivers License Number
*
########FL
Gender
Male
Female
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Do you work for the school system?
Please Select
Yes
No
Occupation
Marital Status
Single
Married
Widowed
Divorced
Separated
Registered Partnership
Other
Are you an AAA member?
Please Select
Yes
No
How did you hear about us? *select all that apply*
Search Engine (Google, Bing, Safari, etc.)
Facebook
Instagram
LinkedIn
Word of Mouth/Referral
School Event and/or Workshop
Mailer or Print Advertisement
Other
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Primary Insured Vehicle
Upload Current Auto Insurance Dec Form
Browse Files
Drag and drop files here
Choose a file
*Optional
Cancel
of
Primary Insured Vehicle
When does your current policy renew?
-
Month
-
Day
Year
Date
Current auto insurance company provider?
Are there additional individuals to insure?
Please Select
Yes
No
Are there additional vehicles to insure?
Please Select
Yes
No
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Additional Vehicle
Insured Vehicle
Are there additional vehicles to insure?
Please Select
Yes
No
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Third Additional Vehicle
Insured Vehicle
Are there additional vehicles to insure?
Please Select
Yes
No
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Fourth Vehicle
Insured Vehicle
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Secondary Insured Individual
Secondary Insured - Full Legal Name
First Name
Last Name
Secondary Date of Birth
-
Month
-
Day
Year
Date
Drivers License State and Drivers License Number
########FL
Occupation
Highest level of education
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
Are there additional individuals to insure?
Please Select
Yes
No
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Third Additional Insured
Additional Insured - Full Legal Name
First Name
Last Name
Additional Insured Date of Birth
-
Month
-
Day
Year
Date
Drivers License State and Drivers License Number
FL #######
Occupation
Highest level of education
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
Are there additional individuals to insure?
Please Select
Yes
No
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Fourth Additional Insured
Additional Insured - Full Legal Name
First Name
Last Name
Additional Insured Date of Birth
-
Month
-
Day
Year
Date
Drivers License State and Drivers License Number
FL #######
Occupation
Highest level of education
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
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Next
Additional Auto Questions
Have any of the drivers in the household received a ticket or violation in the last 3 years?
Yes
No
Has any of the drivers in the household been involved in an at-fault accident in the last 4 years?
Yes
No
Has any of the drivers in the household had their license suspended or received a DUI in the last 5 years?
Yes
No
Are any of the drivers listed enrolled in school and have a 3.0 GPA or better?
Yes
No
Not applicable
Agreement
By submitting this form, I agree to be contacted via text, phone call, or email by Florida Educators Insurance and GAC Wealth Management regarding products and services. I understand that my coverage or policy cannot be changed or updated via this service form.
Agreement & terms.
*
I agree.
Submit
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