AUTO POLICY | PLANNERS INSURANCE GROUP

PLANNERS INSURANCE GROUP | AUTO POLICY INFORMATION

Please fill out the questions below to provide you an accurate quote.
Contact Information

Please put your full name and contact information below:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about us?

FacebookReferralWebsiteOther
Who referred you?

Insured's Information

Please input all the required information below so that we can provide you more accurate quote.
Garaging Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your garaging address?*
Mailing Address*
Do you have a Prior Policy?*
State the Reason*
Example: Has own car and insurance.
Current Carrier*
For how long in Current Carrier*
Please put the number of years or months you've been in that carrier. Example: 2 years; 6months.
Expiration of Policy*

MonthDayYear
Preferred Payment Plan*
Price your are currently paying
Education*
Occupation*
Birth Date*

MonthDayYear
Marital Status*
Spouse's Information

Please input the information of your spouse.
Name

Spouse's First NameSpouse's Last Name
Spouse's Birth date

MonthDayYear
Phone Number
Spouse's phone number.
Email
Spouse's email. example@example.com
Education
Spouse's Education
Occupation
Spouse's Occupation

Drivers
Driver's License *
Primary Driver's License
State*
Primary Driver's License State
Please upload your Driver's License.
Driver's License *
Spouses Driver's License
State*
Spouse's Driver's License State
Please upload your Spouse's Driver's License.
Additional Listed Drivers

If you have additional drivers, please put their Driver's License information below:
How many additional drivers do you have?

EXCLUDED DRIVER'S INFORMATION
Excluded Drivers

Please input the information of the excluded drivers and the reason.
Full name | Date of Birth | Driver's License Number - State | and Reason:
Example: John Smith | June 25, 1898 | 12345678 - TX | Has own car insurance.

Vehicle Information

Please be sure to double check everything before you go next page.
Classic Car
Do you have a Classic Car?*
Please input Year Make & model | VIN Number | and Preferred Coverages:*
Example: Ferrari 250 GTO 1962 | 123456ABCDEF | 30/60/25
Classic Car Declaration Page

Do you have a soft copy of your Classic Car Declaration Page? Upload it here.
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Personal Auto
Do you have additional car?*
How many Vehicles do you want to be Insured?*

Auto Declaration Page

Do you have a soft copy of your Auto Declaration Page? Upload it here.
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Policy Coverages

Please be sure to double check everything before you go next page.
Bodily Injury / Property Damage*
PIP*
Uninsured Motorist BI / PD
Medical*

More about your Auto

Please note anything about your Auto.
Is there anything you would like us to know about your vehicles or driving experience?

BUNDLE YOUR HOME AND AUTO

One of the main benefits of bundling is that companies often offer discounts if you hold several policies with them, so it can save you money. In fact, most carriers will automatically add a multiple-policy discount on both policies, allowing you to save money on your total cost of insurance.
Do you want to bundle you home and auto?*

Home Policy Information
Current Insurance
How long is the insurance lapsed?*
What Carrier?*
Current Carrier*
For how long in Current Carrier?*
Please put the number of years or months you've been in that carrier. Example: 2 years; 6 months.
Expiration of Policy*

MonthDayYear
What is your expected closing date?*

MonthDayYear
Preferred Payment Plan*
Price you are currently paying
Mortgage Information
If you have a mortgage, please input your Mortgage Information here.
Coverage A*
Personal Liability
Medical Payment
Wind/Hail Deductible*
Example: 1%, 2%, $5,000
AOD Deductible*
Example: 1%, 2%, $5,000
Protection Class
Home Declaration Page

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More about Homeowners

Please note anything about your Home.
Is there anything about your home that stands out or is unique that we did not ask?
Please check everything if all details are accurate.
Should be Empty:

PLANNERS INSURANCE GROUP | AUTO POLICY INFORMATION