Auto Quote Form

How did you hear about us?

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you lived at this residence?

Date of Birth

Date

Full Drivers License Number

Drivers License Issue Date

Drivers License Expiration Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do we have permission to communicate via text with you at this number?

Education

Marital Status

Spouse's Name (if none, type N/A)

First NameLast Name

Spouses Full Drivers License Number(if not married, type N/A)

Spouse's Drivers License Issue Date. (if not married, type N/A)

Spouse's Drivers License Expiration Date. (If not married, type N/A)

Spouse's Date of Birth. (If not married, type N/A)

Occupation (If Retired what occupation did you retire from?)

Your Spouse's occupation (If Retired what occupation did they retire from?) If not applicable, type N/A.

Your Spouse's Education

Desired Coverage Start Date

Date

Do you require a sr-22?

Are you the registered owner of the vehicle(s)?

Is your drivers license revoked or suspended?

Personal Vehicle Usage

How many miles do you estimate you drive one way?

How many miles do you estimate you drive a year?

Your Spouse's Personal vehicle usage

How many miles does your spouse estimate they drive one way? If not applicable type N/A

How many miles does your spouse estimate they drive a year? If not applicable type N/A

What were your prior liability limits on your last auto policy? If you're unsure, type "I don't know".

Example 100/300/100 or 250/500/250 etc

About how much is your current carrier charging you every month?

If Farmers Insurance does not beat your current price or coverage options, would you like us to try quoting with other carriers?

Do you currently have a homeowner's policy? If yes, with who?

Do you want Comprehensive Coverage on your vehicles?

Do you want Collision Coverage on your vehicles?

Do you want Towing?

Do you want rental coverage?

Do you want glass coverage?

Do you want medical coverage?

How Many Vehicles do you own?

What is the year, make, model, and VIN number of EACH Vehicle you would like insured?

VIN NUMBER IS REQUIRED FOR QUOTE

Was/Were the vehicle(s) new when purchased?

Does/Do the vehicle(s) have anti-lock brakes?

Does/Do the vehicle(s) have daytime running lights?

Does/Do the vehicle(s) have VIN number etching?

What type of restraints does each vehicle have: A) None, B) Airbag on both sides, C) Auto seatbelts & Driver Airbag, D) Auto seatbelts & Airbag on both sides, or E) Auto seatbelts

How many drivers are in the household?

If you have more drivers to be listed on your policy in addition to the drivers above please list EACH driver's Full name, Date of Birth, Driver's License State, Drivers License Number, Expiration Date & Issued Date. If you do not want to include any other drivers in the household reply: "EXCLUDE ALL OTHER DRIVERS"

Please note quote will not be completed without all of this information. Please make sure if you have teenagers that this is included for them as well.

Select your preferred deductible. (a specified amount of money that an insurance company will deduct from your claim payment) *The higher the deductible, the lower the monthly payment.

Any additional notes you would like us to know?

In connection with this application for insurance, Farmers and Pettigrew Agency partners/affiliates may review your and your spouse’s credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use third parties in connection with the development of your insurance scores based on data from traditional credit bureaus and the National Consumer Telecom & Utilities Exchange database.” Also, do you consent for Farmers and Pettigrew Agency partners/affiliates: (1) to access any available driving scores from a third party based on vehicle telematics data, (2) to use any consumer report information their affiliates might currently have for you for this transaction, and (3) to share consumer report information from this transaction with their affiliates to quote other products?