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Request for car insurance quote
Please fill the form accurately for better assistance
Person & Contact Details
Name
*
First Name
Last Name
Email
*
example@example.com
Enter a valid Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where did you hear about us
Google Ads
Yelp
Facebook
Website
LinkedIn
Other
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Are you currently insured?
*
Yes
No
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
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Do you have additional Vehicles?
*
Yes
No
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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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Driver No. 1
*
Driver No. 1 Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Driver No. 2
Drive No. 2 Marital Status
Please Select
Single
Married
Divorced
Widowed
Driver No. 3
Drive No. 3 Marital Status
Please Select
Single
Married
Divorced
Widowed
Are there any drivers under the age of 25 years of age?
*
Please Select
Yes
No
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Is The Vehicle Financed?
*
Yes
No
Which bank did you finance your vehicle with?
Is your Vehicle used for Private or/and Business?
*
Please Select
Person Use (school and/or work)
Business
Both
Will this Vehicle be used for Share drive (Uber, Lyft, etc)
*
Yes
No
Please Select- Security in Vehicle (select all that apply)
*
Alarm
Tracking
Immobilizer
None
Limits of Liability - Auto
*
Please Select
10/20/10
25/50/25
50/100/50
100/300/50
300/300/100
Other
Deductible for Comprehensive and Collision
*
Please Select
250
500
Other
Medical Payments
*
Please Select
$2,000
$3,000
$5,000
Other
Personal Injury
*
Please Select
$100,000
$300,000
$500,000
$1,000,000
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Are you requesting towing/ roadside assistance?
Please Select
Yes
No
Where is your vehicle parked during the night?
*
Please Select
On the street
In your home garage
In a public parking lot
Other
Have you had any claims in the past 3 years?
*
Yes
No
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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.
Please verify that you are human
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Signature
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