Request Single Vehicle Proposal
Please answer the questions the best you can so we can game plan your next insurance. We represent many carriers and so there is a multitude of questions to cover most carriers. These questions are there to help you get a better rate. Please use Additional Information at the bottom to provide more vehicles, drivers, or any other information. We always try to respond promptly the same day or on the next business day. Thank you for giving 12 Times Better Insurance Plus an opportunity to earn your business.
Personal Information
Do you rent or own your home?
Do you currently have insurance?
If no, when did you last have insurance?
|
|
/ |
|
/ |
|
Date of Birth *
|
|
/ |
|
/ |
|
Marital Status *
Name and approximate date of any moving or non-moving violations the past 3 to 5 years
List and date any at-fault or non-fault accidents, or Comprehensive claims last 5 years
Relationship *
Marital Status *
Date of Birth
|
|
/ |
|
/ |
|
Name and approximate date of any moving or non-moving violations the past 3 to 5 years
Date of Birth *
|
|
/ |
|
/ |
|
Marital Status *
Relationship *
Name and approximate date of any moving or non-moving violations the past 3 to 5 years
List and date any at-fault or non-fault accidents, or Comprehensive claims last 5 years
Collision Deductible
Comprehensive Deductible
Bodily Injury Liability *
Property Damage Liability *
Uninsured Motorist Bodily Injury
Uninsured Motorist Property Damage
Underinsured Motorist - Bodily Injury Limits
Underinsured Motorist - Property Damage Limits
Medical Pay / PIP
Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
online privacy policy we will not resell your information to any third-party.
|