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2. Insurance and Claims

I'm currently insured, or my policy expired less than 30 days ago

Current or last insurance company

GEICO, Progressive, State Farm, etc.

Continuous coverage

Total time insured from any company

Insured length
You may also include coverage under someone else's policy.

How long have you been a customer?

Current policy expires in...

What type of rates would you like to see?

	State Minimum	Standard Coverage	Premium Coverage
Bodily Injury Bodily Injury Liability pays damages for people injured or killed in an accident for which you are legally responsible. The first number in the coverage limit is for any one person; the second is the total coverage limit for one incident or accident.	$25,000 / $50,000	$100,000 / $300,000	$250,000 / $500,000
Property Damage Property Damage Liability pays for damage to other people's property resulting from an accident caused by your auto for which you are legally responsible. $50,000 of coverage is the recommended amount by the Insurance Information Institute.	$25,000	$50,000	$100,000
Medical Medical payments coverage pays the reasonable and necessary medical, dental, hospital and funeral expenses for the insured, covered passengers and family members, who are injured in a covered auto accident, regardless of who was at fault. Coverage is also provided to the insured and resident relatives, while they are riding in someone else's car at the time of the accident or if they are struck as a pedestrian.	You pay	Insurance pays	Insurance pays
Roadside / Rental Roadside pays for towing, jump-starting your car, and other emergencies. If you have AAA or some other auto club membership, you may not need this. Rental coverage pays for a rental vehicle if your car isn't drivable for more than 24 hours because of a covered accident.	You pay	Insurance pays	Insurance pays

Any tickets, accidents, or claims in the past 3 years?

Report an incident or claim

Driver

Person involved

Estimated date

MM/YYYY. OK to estimate. Example 02/2012

Type of ticket

What happened?

Claim type

What was damaged?

Amount paid by insurance

OK to estimate

Was the driver at fault?
Yes No

What happened?

Damage

Driver at fault?
Yes No

Amount paid by insurance

OK to estimate

What state was it in?

3. Contact information

Your information will be kept safe, secure & will only be used to provide quotes.

Email *

A copy of your quote will be sent here. Never junk mail.

Phone number *

Work, home, or mobile

Home Address *

Street

Apartment or unit number

City, state and zip code

How long have you lived here?
Do you own this home?
Yes No

Home ownership
You can often get discounts if you combine your auto and homeowners insurance policies through the same provider or agent.
Do you have a garage?
Yes No

Garage parking
If you vehicle is parked overnight in a garage, you may be eligible for discounts.

* Required for accurate quote

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Fast, free insurance quotes & discounts

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1. Car and Driver

Drive this car to work/school?

How far is work/school?

Average mileage driven each year

Is this car leased?

Deductible for collisions

Collision deductible

Deductible for comprehensive

Comprehensive deductible

Driver name

Gender

Married

Birthday

First licensed

Education level

Primary vehicle

Credit rating

Your credit

Bankruptcy last 5 yrs?

Occupation

Occupation discounts

Active license?

SR-22 Required?

What is an SR-22?

Military Affiliation?

2. Insurance and Claims

Current or last insurance company

Continuous coverage

Insured length

How long have you been a customer?

Current policy expires in...

What type of rates would you like to see?

Any tickets, accidents, or claims in the past 3 years?

Report an incident or claim

Driver

Estimated date

Type of ticket

Claim type

What was damaged?

Amount paid by insurance

Was the driver at fault?

What happened?

Damage

Driver at fault?

Amount paid by insurance

Liability & medical paid

What state was it in?

3. Contact information

Email *

Phone number *

Home Address *

How long have you lived here?

Do you own this home?

Home ownership

Do you have a garage?

Garage parking