AHI Car Insurance Request for Quote

Request for car insurance quote

We value your privacy. Your personal information and vehicle details are secure with us and will not be shared or sold to any outside companies. Please complete the form in its entirety for better assistance. One of our representatives will contact you shortly, typically within 2-4 hours, to finalize your quote.
Person & Contact Details
Name*

First NameLast Name
Email*
example@example.com
Enter a valid Phone Number*
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where did you hear about us

FacebookGoogle AdsLinkedInWebsiteWord of MouthYelpOther

Are you currently insured?*

YesNo
Vehicle No. 1 Information*
Actual Cash Value of Vehicle No. 1*
Original Cost of Vehicle No. 1*
Upload a photo of the car registration for Vehicle No. 1*

Cancelof
Do you have additional Vehicles?*

YesNo

Vehicle No. 2 Information
Actual Cash Value of Vehicle No. 2
Original Cost of Vehicle No. 2
Upload a photo of the car registration for Vehicle No. 2

Cancelof
Vehicle No. 3 Information
Actual Cash Value of Vehicle No. 3
Original Cost of Vehicle No. 3
Upload a photo of the car registration for Vehicle No. 3

Cancelof
Driver No. 1*
Driver No. 1 Marital Status*
Driver No. 2
Drive No. 2 Marital Status
Driver No. 3
Drive No. 3 Marital Status
Are there any drivers under the age of 25 years of age?*

Is The Vehicle Financed?*

YesNo
Which bank did you finance your vehicle with?
Is your Vehicle used for Private or/and Business?*
Will this Vehicle be used for Share drive (Uber, Lyft, etc)*

YesNo
Please Select- Security in Vehicle (select all that apply)*

AlarmTrackingImmobilizerNone
Limits of Liability - Auto*
Deductible for Comprehensive and Collision*
Medical Payments*
Personal Injury*

Are you requesting towing/ roadside assistance?
Where is your vehicle parked during the night?*
Have you had any claims in the past 3 years?*

YesNo

I understand*

Any person who knowingly and with the intent to defraud presents false information in an insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstance prevails, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. Any person who, knowingly and with intent to defraud the insurance company or other person, files an application for insurance containing any false information or conceals for misleading, information containing any fact material thereto, commits a fraudulent insurance act violation, which is a crime.
To whom it may concern;

Dear Sirs:
Please be advised that we have appointed Alfredo Huertas to act as our exclusive insurance representative of record. This appointment authorizes him to represent us in all our insurance matters, including all aspects of marketing, placement, and administration.

This letter supersedes all other letters of authorization and broker of record appointments on file. This authorization will remain in effect until you receive written notification from us to the contrary.

Mr. Huertas is authorized to acquire and manage all information related to these insurance matters. He is not responsible for any deficiencies in our current insurance programs or policies, or for any errors or omissions that occurred before this appointment.

Sincerely,

First Name Last Name Date
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Request for car insurance quote

Person & Contact Details