Independent Insurance Agency
Serving Alliance, Massillon, Canton and Stark County since 1874

Automobile Insurance Quote Form



To help us supply you with the most accurate car insurance quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name: *
Last Name: *
E-mail Address: *
Daytime Phone:
Evening Phone:
Fax:
How would you prefer to be contacted regarding your quote?

If you would prefer to be contacted by phone, please let us know the best time to call.

Address:
City:
State:
Zip Code:
Do you own or rent your home?

Driver's License Number:
Social Security Number:

DRIVER INFORMATION

DRIVER #1

Name:
Relationship to Applicant:
Sex:

Marital Status:

Driver's Age:
Which vehicle does he/she drive?

Percent Use:

DRIVER #2

Name:
Relationship to Applicant:
Sex:

Marital Status:

Driver's Age:
Which vehicle does he/she drive?

Percent Use:

DRIVER #3

Name:
Relationship to Applicant:
Sex:

Marital Status:

Driver's Age:
Which vehicle does he/she drive?

Percent Use:

DRIVER #4

Name:
Relationship to Applicant:
Sex:

Marital Status:

Driver's Age:
Which vehicle does he/she drive?

Percent Use:

DRIVER HISTORY

 
Currently insured with (company name, not agency):

 

Have you or any other driver in your household:

Had a ticket in the last 3 years?

Had a license suspended or revoked in the last 6 years?

Had a financial responsibility filing in the last 6 years?

Made any claims in the last 5 years?

If you answered yes to any of the above questions, please explain:


VEHICLE INFORMATION

VEHICLE #1

Year:
Make:
Model:
Vehicle ID# (VIN):
Primary Driver:
Annual Mileage:
Is the vehicle driven to school or work?

If driven to school or work, how many days per month?
If driven to school or work, how many weeks per month?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?
Is there any existing damage to the vehicle?

If the vehicle is kept at an address other than that listed above, please indicate below:

Address:

City:

State:

Zip:

VEHICLE #2

Year:
Make:
Model:
Vehicle ID# (VIN):
Primary Driver:
Annual Mileage:
Is the vehicle driven to school or work?

If driven to school or work, how many days per month?
If driven to school or work, how many weeks per month?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?
Is there any existing damage to the vehicle?

If the vehicle is kept at an address other than that listed above, please indicate below:

Address:

City:

State:

Zip:

VEHICLE #3

Year:
Make:
Model:
Vehicle ID# (VIN):
Primary Driver:
Annual Mileage:
Is the vehicle driven to school or work?

If driven to school or work, how many days per month?
If driven to school or work, how many weeks per month?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?
Is there any existing damage to the vehicle?

If the vehicle is kept at an address other than that listed above, please indicate below:

Address:

City:

State:

Zip:

VEHICLE #4

Year:
Make:
Model:
Vehicle ID# (VIN):
Primary Driver:
Annual Mileage:
Is the vehicle driven to school or work?

If driven to school or work, how many days per month?
If driven to school or work, how many weeks per month?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?
Is there any existing damage to the vehicle?

If the vehicle is kept at an address other than that listed above, please indicate below:

Address:

City:

State:

Zip:

COVERAGE DEDUCTIBLES

VEHICLE #1

Comprehensive deductible:

Ccollision deductible:

Towing coverage deductible:

VEHICLE #2

Comprehensive deductible:

Ccollision deductible:

Towing coverage deductible:

VEHICLE #3

Comprehensive deductible:

Ccollision deductible:

Towing coverage deductible:

VEHICLE #4

Comprehensive deductible:

Ccollision deductible:

Towing coverage deductible:

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?


Additional information: Leave Blank to Submit the Form.

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