Auto/Motorcycle/Boat Quote Request Form

(see ACTUAL AUTO RATES)

  1. Please fill in the personal information below, then complete the vehicle information.
    We will prepare a quote and mail it to you.

  2. If you prefer, you may call 1-(865)-824-2730 (toll free) for a phone quote. Or you can fax a copy of your policy to 1-(877)-699-0089 (toll free) and a quote will be faxed to you. (If you fax your policy, please include your home and work phone numbers so we can call if we need additional information to complete your quote).

  3. Please remember to fill in your email address for a prompt response to your request.

  4. DON'T CHEAT YOURSELF-If you currently have more than "one" car insured, please allow us to "quote" all of your cars also. If we quote only one car (and that car is currently insursed in a multi car account) you "CHEAT YOURSELF" out of a 15% multi car discount. DON'T FORGET THE 10% DISCOUNT that is available if you let us quote your homeowners insurance also.

Personal Information

**Your zip code must be provided in order to process your request.

First Name: Last Name:
Address: Suite/Unit:
City: State:
Zip: Email Address:
Business Phone: Home Phone:
Fax: Soc. Security#:

Auto/Motorcycle/Boat Information

(For Motorcycles also please list the CC's in Additional Comments below)

(For boats, in additional comments below, please list Length of boat, Horse Power of Motor, Is boat outboard, inboard, inboard/outboard, dollar value of boat, dollar value of motor, dollar value of trailer.)

Current Carrier Information

What is the expiration date of your current automobile policy?

Who is your current auto insurance carrier? (not agency)

Have you been continuously insured for the past six months? Yes No

Are you an insured homeowner? This could give additional discounts. Yes No

Vehicle Information

List the vehicles currently insured and/or want insured in your household.

Year Make Model EXAMPLE: YEAR 1996
MAKE HONDA
MODEL ACCORD LX 4 DOOR (THIS LINE IS IMPORTANT TO GET AN ACCURATE QUOTE)
Vehicle 1
Vehicle 2 EXAMPLE: YEAR 1995
MAKE JEEP
MODEL GRAND CHEROKEE LAREDO 4 DOOR (THIS LINE IS IMPORTANT TO GET AN ACCURATE QUOTE)
Vehicle 3
Vehicle 4  
Use of Vehicle 1 (required)
Use of Vehicle 2 (if applicable)
Use of Vehicle 3 (if applicable)
Use of Vehicle 4 (if applicable)

Comprehensive Coverage (fire, theft, vandalism and glass breakage)

Deductible Vehicle 1 (if applicable)           

Deductible Vehicle 2 (if applicable)             

Deductible Vehicle 3 (if applicable)

Deductible Vehicle 4 (if applicable)

Collision Coverage

Deductible  Vehicle 1 (if applicable)             

Deductible  Vehicle 2 (if applicable)             

Deductible  Vehicle 3 (if applicable)

Deductible  Vehicle 4 (if applicable)

Driver Information

Who are the drivers in your household?

Driver 1Driver 2Driver 3Driver 4
Name:
Date of Birth:
Sex:
Marital Status:

Do you have any accidents * or violations?

Driver 1Driver 2Driver 3Driver 4
Violation Date:
Violation Code:
Violation Date:
Violation Code:

Coverage Information

What are your Current Bodily Injury and

Property Damage limits of liability:      


Additional Comments:

For Motorcycles, please list

CC of cycle in 'Additional Comments' to the left.

For boats please list:

Length of boat, Horsepower of motor, Is boat an Outboard, Inboard, Inboard/Outboard, Dollar value of boat, Dollar value of motor, Dollar value of trailer in 'Additional Comments'

 
 

(An at fault accident is any accident where you collected from your own company under collision coverage, or an accident where your company paid someone else in your behalf. A not at fault accident is where you were reimbursed by the other company, or you collected from your own company under uninsured motorist.)
 

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