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Pettigrew Agency
Auto Quote Form
How did you hear about us?
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Ashlyne
Darren
Kiffany
Google
Facebook
Other Social Media
A Customer Referred Me
Newspaper Ad
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this residence?
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Date of Birth
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Month
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Day
Year
Date
Full Drivers License Number
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Drivers License Issue Date
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Drivers License Expiration Date
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Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Do we have permission to communicate via text with you at this number?
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Yes
No
Education
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No high school diploma
High school diploma
Some college- no degree
Vocational technical degree
Associates degree
Bachelors
Masters
Phd
Medical degree
Law degree
Marital Status
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Married
Single
Divorced
Spouse's Name (if none, type N/A)
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First Name
Last Name
Spouses Full Drivers License Number(if not married, type N/A)
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Spouse's Drivers License Issue Date. (if not married, type N/A)
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Spouse's Drivers License Expiration Date. (If not married, type N/A)
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Spouse's Date of Birth. (If not married, type N/A)
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Occupation (If Retired what occupation did you retire from?)
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Your Spouse's occupation (If Retired what occupation did they retire from?) If not applicable, type N/A.
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Your Spouse's Education
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Please Select
Not applicable
No high school diploma
High school diploma
Some college- no degree
Vocational technical degree
Associates degree
Bachelors
Masters
Phd
Medical degree
Law degree
Desired Coverage Start Date
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/
Month
/
Day
Year
Date
Do you require a sr-22?
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Are you the registered owner of the vehicle(s)?
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Yes
No
Is your drivers license revoked or suspended?
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Yes
No
Personal Vehicle Usage
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Please Select
Pleasure
To/From Work
To/From school
How many miles do you estimate you drive one way?
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How many miles do you estimate you drive a year?
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Your Spouse's Personal vehicle usage
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Please Select
Not applicable
Pleasure
To/From Work
To/From School
How many miles does your spouse estimate they drive one way? If not applicable type N/A
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How many miles does your spouse estimate they drive a year? If not applicable type N/A
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What were your prior liability limits on your last auto policy? If you're unsure, type "I don't know".
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Example 100/300/100 or 250/500/250 etc
About how much is your current carrier charging you every month?
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If Farmers Insurance does not beat your current price or coverage options, would you like us to try quoting with other carriers?
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Yes
No
Do you currently have a homeowner's policy? If yes, with who?
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Do you want Comprehensive Coverage on your vehicles?
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Yes
No
Do you want Collision Coverage on your vehicles?
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Yes
No
Do you want Towing?
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Yes
No
Do you want rental coverage?
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Yes
No
Do you want glass coverage?
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Yes
No
Do you want medical coverage?
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Yes
No
How Many Vehicles do you own?
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What is the year, make, model, and VIN number of EACH Vehicle you would like insured?
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VIN NUMBER IS REQUIRED FOR QUOTE
Was/Were the vehicle(s) new when purchased?
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Does/Do the vehicle(s) have anti-lock brakes?
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Does/Do the vehicle(s) have daytime running lights?
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Does/Do the vehicle(s) have VIN number etching?
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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
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How many drivers are in the household?
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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"
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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.
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$500
$1000
$2000
$2500
Any additional notes you would like us to know?
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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?
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Yes, I Consent.
Submit & complete optional warranty quote
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