Name
*
First Name
Last Name
First Name
*
First Name
Last Name
*
First Name
Email
*
example@example.com
What's your Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at your current address?
*
0-6 Months
6-12 Months
Over a Year
What was your previous address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you own or rent your home?
*
Own
Rent/Stay with Family
Phone Number
*
Do we have your permission to contact you via text? We will NOT spam you and you can unenroll at any time. Some folks prefer to be reached out via text, and you will not be solicited in any way. We will not share your information either.
*
Please Select
Yes
No
By clicking YES you consent to receiving SMS messages. Messages and Data rates may apply. Message frequency will vary. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. Reply Help to get more assistance Reply STOP to Opt-Out of Messaging. For full details on our data use and your privacy, please visit our website. Our privacy policy is at the bottom of every page. https://griffininsurancesc.com/privacy-policy/
Date of Birth
*
-
Month
-
Day
Year
Date
What's your gender?
*
Please Select
Male
Female
What's your relationship status?
*
Please Select
Single
Married
What's the full name of your spouse?
*
First Name
Last Name
Spouse date of birth?
*
-
Month
-
Day
Year
Date
What's Your Driver's License # and State that You are Licensed?
*
Driver's License #
Licensed State
What's Your Spouse's Driver's License # and what State are they Licensed?
*
Driver's License #
Licensed State
What's your occupation?
*
What's your highest level of education?
*
Please Select
Some High School
High School Diploma
Some College
College Degree
Will there be another driver on this policy?
*
Yes
No
Full Name of 2nd Driver
First Name
Last Name
Date of Birth of 2nd Driver
-
Month
-
Day
Year
Date
Gender of 2nd Driver?
Please Select
Male
Female
2nd Driver: What's Your Driver's License # and State that You are Licensed?
*
Driver's License #
Licensed State
2nd Driver's Phone Number
*
Please enter a valid phone number.
2nd Driver's Occupation
Are there any more drivers on this policy?
*
Yes
No
Full Name of 3rd Driver
*
First Name
Last Name
Date of Birth of 3rd Driver
*
-
Month
-
Day
Year
Date
Gender of 3rd Driver?
*
Please Select
Male
Female
3rd Driver: What's Your Driver's License # and State that You are Licensed?
*
Driver's License #
Licensed State
3rd Driver's Phone Number
*
Please enter a valid phone number.
Are there any more drivers on this policy?
*
Yes
No
Full Name of 4th Driver
*
First Name
Last Name
Date of Birth of 4th Driver
*
-
Month
-
Day
Year
Date
Gender of 4th Driver?
*
Please Select
Male
Female
4th Driver: What's Your Driver's License # and State that You are Licensed?
*
Driver's License #
Licensed State
4th Driver's Phone Number
*
Please enter a valid phone number.
Are there any more drivers on this policy?
*
Yes
No
Full Name of 5th Driver
*
First Name
Last Name
Date of Birth of 5th Driver
*
-
Month
-
Day
Year
Date
Gender of 5th Driver?
*
Please Select
Male
Female
5th Driver: What's Your Driver's License # and State that You are Licensed?
*
Driver's License #
Licensed State
5th Driver's Phone Number
*
Please enter a valid phone number.
Are there any more drivers on this policy?
*
Yes
No
List Full Name, Date of Birth, Driver's License #, and State each additional driver is licensed in
*
Did you want a vehicle on this quote?
*
Yes - I want to add a vehicle on to this quote
No - I want non-owner insurance (no vehicle, just me)
What's the Year, Make and Model of Your 1st Vehicle?
*
Year
Make
Model
What's the VIN # of your 1st vehicle?
*
Must be 17 Characters. Required for accurate quote. If you don't have it, just put in 17 "0"s.
How long have you owned this vehicle?
*
Less than 3 months
3-6 months
6-12 months
1-3 years
Over 3 years
For This Vehicle, Do You Need Comprehensive and Collision Coverage? Comprehensive coverage is if you hit a deer, if a rock hits your windshield, if your vehicle is stolen, etc. Collision is if you run into someone. (If you are financing this vehicle, the answer will be YES.
*
Yes
No - I Want Liability Only
What kind of deductibles would you like for your comprehensive and collision coverage?
*
Please Select
250
500
1000
2000
As High As Possible
The higher the deductible, the lower the price, HOWEVER, the higher deductible the less you will receive in the event of a claim!
Did You Want Any Additional Coverages?
Rental Reimbursement (coverage if you are at fault in an accident and need a vehicle while your vehicle is being repaired or totaled. Coverage is typically up to 30 days.)
Roadside Coverage (limited coverage if you get a flat tire, get locked out of your vehicle, etc)
Add on GAP Coverage (If Available)
Nope! Just Comprehensive and Collision
Do You Want Another Vehicle on This Quote?
*
Yes
No
What's the Year, Make and Model of your 2nd Vehicle?
*
Year
Make
Model
What's the VIN # of your 2nd vehicle?
*
Must be 17 Characters. Required for accurate quote. If you don't have it, just put in 17 "0"s.
How long have you owned this vehicle?
*
Less than 3 months
3-6 months
6-12 months
1-3 years
Over 3 years
For Your 2nd Vehicle, Do You Need Comprehensive and Collision Coverage? Comprehensive coverage is if you hit a deer, if a rock hits your windshield, if your vehicle is stolen, etc. Collision is if you run into someone. (If you are financing this vehicle, the answer will be YES.
Yes
No - I Want Liability Only
Vehicle #2: What kind of deductibles would you like for your comprehensive and collision coverage?
*
Please Select
250
500
1000
2000
As High As Possible
The higher the deductible, the lower the price, HOWEVER, the higher deductible the less you will receive in the event of a claim!
Vehicle #2: Did You Want to Add On Any Additional Coverages?
*
Add on Rental Reimbursement Coverage
Add on Roadside Coverage
Add on GAP Coverage (If Available)
Nope! Just Comprehensive and Collision
Do You Want Another Vehicle on This Quote?
*
Yes
No
What's the Year, Make and Model of your 3rd Vehicle?
*
Year
Make
Model
What's the VIN # of your 3rd vehicle?
*
Must be 17 Characters
How long have you owned this vehicle?
*
Less than 3 months
3-6 months
6-12 months
1-3 years
Over 3 years
For Your 3rd Vehicle, Do You Need Comprehensive and Collision Coverage? Comprehensive coverage is if you hit a deer, if a rock hits your windshield, if your vehicle is stolen, etc. Collision is if you run into someone. (If you are financing this vehicle, the answer will be YES.
*
Yes
No - I Want Liability Only
Vehicle #3: What kind of deductibles would you like for your comprehensive and collision coverage?
*
Please Select
250
500
1000
2000
As High As Possible
The higher the deductible, the lower the price, HOWEVER, the higher deductible the less you will receive in the event of a claim!
Vehicle #3: Did You Want to Add On Any Additional Coverages?
*
Add on Rental Reimbursement Coverage
Add on Roadside Coverage
Add on GAP Coverage (If Available)
Nope! Just Comprehensive and Collision
Do You Want Another Vehicle on This Quote?
*
Yes
No
What's the Year, Make and Model of your 4th Vehicle?
*
Year
Make
Model
What's the VIN # of your 4th vehicle?
*
Must be 17 Characters
How long have you owned this vehicle?
*
Less than 3 months
3-6 months
6-12 months
1-3 years
Over 3 years
For Your 4th Vehicle, Do You Need Comprehensive and Collision Coverage? Comprehensive coverage is if you hit a deer, if a rock hits your windshield, if your vehicle is stolen, etc. Collision is if you run into someone. (If you are financing this vehicle, the answer will be YES.
*
Yes
No - I Want Liability Only
Vehicle #4: What kind of deductibles would you like for your comprehensive and collision coverage?
*
Please Select
250
500
1000
2000
As High As Possible
The higher the deductible, the lower the price, HOWEVER, the higher deductible the less you will receive in the event of a claim!
Vehicle #4: Did You Want to Add On Any Additional Coverages?
*
Add on Rental Reimbursement Coverage
Add on Roadside Coverage
Add on GAP Coverage (If Available)
Nope! Just Comprehensive and Collision
Do You Want Another Vehicle on This Quote?
*
Yes
No
What's the Year, Make and Model of your 5th Vehicle?
*
Year
Make
Model
What's the VIN # of your 5th vehicle?
*
Must be 17 Characters
How long have you owned this vehicle?
*
Less than 3 months
3-6 months
6-12 months
1-3 years
Over 3 years
For Your 5th Vehicle, Do You Need Comprehensive and Collision Coverage? Comprehensive coverage is if you hit a deer, if a rock hits your windshield, if your vehicle is stolen, etc. Collision is if you run into someone. (If you are financing this vehicle, the answer will be YES.
*
Yes
No - I Want Liability Only
Vehicle #5: What kind of deductibles would you like for your comprehensive and collision coverage?
*
Please Select
250
500
1000
2000
As High As Possible
The higher the deductible, the lower the price, HOWEVER, the higher deductible the less you will receive in the event of a claim!
Vehicle #5: Did You Want to Add On Any Additional Coverages?
*
Add on Rental Reimbursement Coverage
Add on Roadside Coverage
Add on GAP Coverage (If Available)
Nope! Just Comprehensive and Collision
Do You Want Another Vehicle on This Quote?
*
Yes
No
Please type in the VIN for any other vehicles and coverage preference
*
Do You Currently Have Insurance?
*
Yes
No
How Long Has It Been Since You've Had Insurance?
*
Never Had It
Less Than 30 Days
Over 30 Days
Who do you currently have insurance with?
*
What's your current monthly premium?
How long have you been with your current insurance carrier?
*
Less than 6 months
6-12 months
1-3 Years
3 or more years
If you are unsure what your coverage is, feel free to upload your current policy here and I'll compare for you! (Optional)
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What level of Liability Protection would you like?
*
25,000/50,000/25,000 (State Minimum)
50,000/100,000/50,000 (Good)
100,000/300,000/100,000 (Better)
250,000/500,000/100,000 (Best)
Some insurance carriers offer a discount if you wanted a telematics app on your phone. It tracks your driving habits for 90 days (watches if you play on your phone while you drive, and checks to see if you speed). This app is free and knocks 10% off your quote and up to 30% off of your renewal. Would you be interested?
*
Yes
No
Including Non-Drivers, how many people live at your address?
*
Please Select
1
2
3
4
5
6
7
8+
When would you like coverage to start? (If you currently have insurance, then select when your next payment is due)
*
-
Month
-
Day
Year
Date
Does anyone need SR22?
*
Yes
No
Any violations in the past 5 Years?
*
Yes
No
Please list any violations that you know about and the dates if you can remember
Is there any existing damage to any of the vehicles?
*
Yes
No
Are there any other details we need to know?
How do you prefer to be contacted?
*
Phone Call
Email
Text (By clicking this, you give us permission to contact you via text)
State 3rd Driver is licensed in?
Driver's License number of 3rd Driver
*
Driver's License number of 2nd Driver
*
State 2nd Driver is licensed in?
What's your driver's license number?
*
In what state are you licensed to drive?
*
3rd Driver's Occupation
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