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Online Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name (First & Last):
Street Address:
City:
State:
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
(Stick Built)
Yes No
 
Mobile Homeowner?
(Single or Doublewide)
Yes No
Total # of Members
in Household:

(age 14 and over)
 
Do you have Medical Insurance?
(If YES, list company below)
Yes No
 
Are Your Currently Insured?
(If YES, list answers to questions below)
Yes No
Carrier Name:
Bodily Injury Limits:
# Months of continuous coverge:
Renewal Date if Known:

 


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): Male
Female
Relationship to Insured:
Please list all "Tickets", "Accidents" (At fault and/or Not-at-fault), and "Comprehensive" claims in the last 3 years below.
Be specific as to the TYPE of TICKETS, and approximate dates:
Occupation & Name of Employer: Daily commute
in ONE WAY miles:

 

DRIVER INFORMATION #2
Name: Birthdate:
Sex (M/F): Male
Female
Relationship to Insured:
Please list all "Tickets", "Accidents" (At fault and/or Not-at-fault), and "Comprehensive" claims in the last 3 years below.
Be specific as to the TYPE of TICKETS, and approximate dates:
Occupation & Name of Employer: Daily commute
in ONE WAY miles:


ADDITIONAL DRIVER INFORMATION
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:


YOU'RE ALMOST DONE...SIMPLY COMPLETE VEHICLE INFORMATION!

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make:
Model: VIN# (if known, for rating accuracy):
Vehicle used in business? Yes No If YES, explain business usage:
VEHICLE #1 COVERAGES:
Select Coverages

 
DEDUCTIBLES BELOW DO NOT APPLY TO PL/PD ONLY COVERAGE

Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO

 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make:
Model: VIN# (if known, for rating accuracy):
Vehicle used in business? Yes No If YES, explain business usage:
VEHICLE #2 COVERAGES:
Select Coverages

 
DEDUCTIBLES BELOW DO NOT APPLY TO PL/PD ONLY COVERAGE>

Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
ADDITIONAL VEHICLE INFORMATION
If More than 2 Vehicles, list Additional Vehicles Year, Make, Model, Vin# and Coverages here:


Additional Comments or Remarks Here:


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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Thank you for visiting the insurance web site of Troyer Insurance Agency, Inc.
E-Mail: troyerinsurance@aol.com   |   More About our Agency's Services
1015 N. Nottawa Street   Sturgis, MI 49091   (Click for Map/Directions)    |    Phone: 269-651-9060
Toll Free Phone: 800-617-9060    |    Fax: 269-651-5253   |    © 2007 Insurance-Web-Sales
Privacy Notice/Copyright Info.    |   Questions/site-related problems, please E-mail us at: troyerinsurance@aol.com