Your Name:
Address:
City:
State:
Zip:
Primary residence:
Select
Rent
Own Home
Own Condo
Own Mobile Home
Live w/ Parent
Other
Home Phone:
Business Phone:
E-mail:
Fax:
How would you like to be contacted?
Select
Home Phone
Business Phone
Fax
Email
Are you a member of any group?
Select
AARP
Credit Union
MEA
College Alumni
Farm Organization
Condo Association
Neighborhood Assoc.
Lions Club
Rotary
VFW
Other
Current Auto Insurance:
Do you have current auto insurance?
Select
Yes
No, Recently lapsed/canceled
No, Insured's first car
No, FIX THIS
No, other reason
Current auto insurance company?
None
AAA
Allstate
Auto Owners
Bristol West
Citizens
Farm Bureau
Farmers Insurance
Fremont Ins. Co.
Michigan Ins. Co.
Pioneer Mutual
Progressive
State Farm
Titan
Other
Years with this insurance company?
Select
1
2
3
4
5 or more
Current liability limits?
Select
20/40
50/100
100/300
250/500
500/500
Drivers in your household:
How many licensed drivers in your household?
Select
1
2
3
4 or more
Driver
Name
Date of Birth
Last 5 years
Marital Status
Tickets
Accidents
1
No
Yes
None
1
2
3
4 or More
None
At Fault
Not at Fault
Single
Married
2
No
Yes
None
1
2
3
4 or More
None
At Fault
Not at Fault
Single
Married
3
No
Yes
None
1
2
3
4 or More
None
At Fault
Not at Fault
Single
Married
4
No
Yes
None
1
2
3
4 or More
None
At Fault
Not at Fault
Single
Married
About your Vehicles:
How many licensed vehicles are in your household?
1
2
3 or more
Vehicle 1:
Titled Owner:
Year:
Make:
Model:
VIN:
Primary use:
Pleasure
Business
To Work/school
Farm use only
Annual Mileage:
0 - 3,000
3,000 and over
Vehicle 2:
Titled Owner:
Year:
Make:
Model:
VIN:
Primary use:
Pleasure
Business
To Work/school
Farm use only
Annual Mileage:
0 - 3,000
3,000 and over
Vehicle 3:
Titled Owner:
Year:
Make:
Model:
VIN:
Primary use:
Pleasure
Business
To Work/school
Farm use only
Annual Mileage:
0 - 3,000
3,000 and over
Vehicle 4:
Titled Owner:
Year:
Make:
Model:
VIN:
Primary use:
Pleasure
Business
To Work/school
Farm use only
Annual Mileage:
0 - 3,000
3,000 and over
Desired coverage and limits:
Please select desired coverage and limits from the following drop-down menus.
Vehicle
Collision
Options
Collision
Deductible
Comprehensive
Deductible:
Car Rental
(per day)
Towing
Vehicle 1:
None
Broad
Basic
Limited
None
$250
$500
$1000
0
$50
$100
$250
$500
None
None
$20
$30
$40
None
Yes
No
Vehicle 2:
None
Broad
Basic
Limited
None
$250
$500
$1000
0
$50
$100
$250
$500
None
None
$20
$30
$40
None
Yes
No
Vehicle 3:
None
Broad
Basic
Limited
None
$250
$500
$1000
0
$50
$100
$250
$500
None
None
$20
$30
$40
None
Yes
No
Vehicle 4:
None
Broad
Basic
Limited
None
$250
$500
$1000
0
$50
$100
$250
$500
None
None
$20
$30
$40
None
Yes
No
FYI
:
Some companies offer substantial savings on both your Auto and Homeowners Insurance rates when they write both. Check here if you are interested in a combined quote, and fill out our Auto Quote form.
© 2007 Newaygo Insurance Agency, Inc.