Your full name:      
Your occupation & employer
Spouse occupation/employer:
Your email address:              
Your home phone number:    
Your work phone number:    
Your home street address:    
Your city:                             

Your State:                            (IF NOT SOUTH CAROLINA, STOP HERE!)
Your ZIP Code:                   
Number of People in House:

Choose One: Own Mobile Home<10 yrs old;   Own Home; Rent;  Live w Parents; Other
What company insures your home/personal property?

We can likely save you the most money by packaging your auto insurance with either a homeowners policy or a renters policy with our special "Multi-Policy" discounts!!  When you are done here, grab that policy and go to our homeowners quote page.  There is a link at the end of this input.

Medical Ins. Company or NONE:   
Disability Ins. Company or NONE:   If you have a disability plan through work that would pay your lost income if you couldn't work due to auto accident injuries.

Do you have Auto Ins in force now?  IF NOT, STOP HERE AND CALL US FOR QUOTE.
If so, Current Auto Ins. Co.:             
Policy Number:                               There will be no response to your request if not included.
Expiration Date:                               
Current 6 mo premium                     

Are you being cancelled by your current company?  If so, WHY?
Are you a member of a group (a college Alumni Assoc, AARP, MEA, Mi Assoc Comm Bankers, etc.) Which?

HOUSEHOLD INFO: List info on ALL household members including yourself(even if they don't drive) AND any other drivers

Are there any more household members? Yes;   No  If so, please list their info at the end in "Other Comments".

 

•  

  TICKETS AND/OR ACCIDENTS IN LAST 5 YEARS FOR ALL HOUSEHOLD MEMBERS AND DRIVERS; PLEASE LIST DETAILS     
  Please give all details on any tickets or accidents for all members of the household during the last 5 years. Be sure to include 1) name of driver, 2) date of occurance, 3) description of occurance, and 4) amount of claim if applicable.  If there have been absolutely none, please state "None"
   

..

CLAIM DETAILS IN LAST 5 YEARS.  Please describe all claims you have had in the last 5 years including deer, windshield, theft, accidents(including "not at fault"), etc..  Provide details, dates, and amounts paid for the claim.  If there have been absolutely none, please state "None"

(You can keep typing past the end of the box)

 

  AUTO INFORMATION    
Car1

Bodily Injury Liability Limits

Please choose a liability limit from the limits listed below. Limits are per person/per occurance. Limits will be the same for all vehicles.  This covers you if you injure someone and they sue you. With law suits the way they are today, we recommend the highest limits possible and we also recommend that you obtain an umbrella policy to "blanket" over your home and auto insurance.  Ask us about it.

Property Damage Liability Limits:

Please choose a property damage liability limit from the list below. Limits will be the same for all vehicles. This covers you if you damage someone's property outside of Michigan (ie parked car, house, etc.) and they sue you.  If you damage property IN Michigan, coverage is automatically up to $1,000,000 as part of Michigan's no-fault insurance laws.
$50,000 $100,000 $250,000 $500,000      

                
Personal Injury Protection-Medical - Enter whether you want
           "Coordinated/Excess" or "Full"  Medical      
           If you don't have medical insurance, or if your medical insurance excludes auto accidents, then you should have "Full".  You should only choose Excess if you have medical insurance and it doesn't exclude auto accidents.  If you are on Medicare or Medicaid, you need "Full" because they don't pay for auto accident related medical bills.  With Excess, your medical pays first, and then your auto insurance "kicks" in after a $300 deductible.  There is no deductible with "Full".  Excess is less expensive than Full.

Enter your Medical choice Coordinated/Excess Medical Full/Primary Medical      

.     
Personal Injury Protection-Wage Loss - Enter whether your want
           "Coordinated/Excess", or "Full"  wage loss  
           If you don't have disability insurance to pay your lost income from work, you should have "Full".  You should only choose Excess if you have disability insurance over and above worker's comp. With excess, your disability insurance pays first, and then your auto insurance "kicks" in after a $300 deductible.  There is no deductible with "Full"..

Enter your Wage Loss choice Coordinated/Excess Wage Loss Full/Primary Wage Loss    

.    

Good Student Discount Note: If any of the drivers is a full time student and on the honor roll/dean's list, please let us know in the extra comments section.  You may be eligible for a "Good Student Discount"

Extra comments; enter additional household member info, additional autos, good student info, etc.:

 Did you fill in all the information?  Did you have your existing policy in front of you to ensure "apples-to-apples"?

How did you find our site?  Yahoo Other Search Engine Referral From a Friend/Relative Ad in Detroit News Ad in Chelsea Standard Ad in Wall St. Journal Ad in Lansing State Journal Ad in Jackson Cit. Pat Ad in Town Crier Radio Ad Television Ad Received Info in Mail Other

If "Other search engine" or "Other" or "Friend", Please list friend or which engine?

Did you find our quote form easy to use?  Put any ideas for improvements here:

Thank you for completing our online quote form. Please let us know how you would like us to send you the quote:

 Phone Call     Fax  

If you entered "phone call" and we call at night, how late can we call you?

If you entered "Fax", what is your fax number: