Automobile Insurance

Automobile Insurance
Quote Request

 

Request a free quote for Auto Insurance

Please complete the form as best as you can. We will contact you as soon as possible to discuss the policy that best fits your needs and budget.

First Name
Last Name:
Address:
 
City:
State:
Zip:
Phone Number:
E-mail:
Vehicle Information:
Vehicle #1:
(Year, Make & Model):
Vehicle #2:
(Year, Make & Model):
Driver Information - Driver #1
Driver Name:
Date of Birth:
Years Licensed:
License Number:
State Licensed:
Which vehicle is this person the principle operator of?
Vehicle #1
Vehicle #2
Driver Information - Driver #2
Driver Name:
Date of Birth:
Years Licensed:
License Number:
State Licensed:
Which vehicle is this person the principle operator of?
Vehicle #1
Vehicle #2
Coverage’s
Part 1 - Bodily Injury Injury to Others
$20,000 per person, $40,000 per accident (Mandatory)
Part 2 - Personal Injury Protection
$8000 (Mandatory)
Part 3 - Uninsured Motorist
$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident

Part 4 - Property Damage (Each Accident)
$25,000 $50,000 $100,000

Part 5 - Optional Bodily Injury
$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident
Part 6 - Medical Payments
No Coverage $5,000 $10,000 $15,000 $25,000
Part 7 - Collision Coverage
Collision Coverage Deductibles
Vehicle #1
No Coverage
$300
$500
$1,000
Vehicle #2
No Coverage
$300
$500
$1,000
Part 9 - Comprehensive Coverage
Comprehensive Coverage Deductibles
Vehicle #1
No Coverage
$300
$500
$1,000
Vehicle #2
No Coverage
$300
$500
$1,000

Part 10 - Substitute Transportation
Vehicle #1
No Coverage
$15 per day, maximum $450
$30 per day, maximum $900
$45 per day, maximum $1350
Vehicle #2
No Coverage
$15 per day, maximum $450
$30 per day, maximum $900
$45 per day, maximum $1350
Part 11 - Towing
Vehicle #1
No Coverage
$50 per disablement
$100 per disablement
 Vehicle #2
No Coverage
$50 per disablement
$100 per disablement
Part 12 - Underinsured Motorist
$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident
Additional Information
Is any vehicle driven under 7,500 miles per year? Please comment including estimated annual miles driven:

Are you a member of AAA auto club?
Yes No
Do you currently have insurance?
Yes No

Name of Current Insurance Company

Current Policy Expiration Date, if known

Some home insurers provide discounts if the auto and home insurance is packaged together.
Do you own a home?
Yes No
If so, please provide the name of the home insurance company, if known


Good Student Discount. Does any student have a B average or equivalent?
Yes No
Has any operator attended a defensive driver training course?
Yes No

Comments
Disclaimer Notice Your request for a premium quotation will be an estimate based on this information, and coverage cannot be bound with your quote request. In order for Kerrigan, O'Malley & Bailey Insurance Agency to bind coverage, a completed application signed by you along with a down payment of premium must be received prior to the effective date.