Quote Form for Auto Insurance

We write a lot of policies for auto insurance. The reason why is we provide quality service at a competitive rate. In order to provide you with a quotation, we need to know more about you and your needs. Please complete the form below and we will respond within 24 hours (business days).

Information about you:

Name:

(required)

E-Mail:

(required)

Phone:

Best time to call:

Policy number:

(Policy number field for current insurance clients only)

Do you have auto insurance currently?

Yes No

For how many years have you been an insured driver?

years

Information about drivers to be insured:

	Driver 1	Driver 2	Driver 3
Name:
Birthdate:
Drivers license #:
# of accidents, 3 yrs:
# of tickets, last 3 yrs:

Information about vehicles to be insured:
	Vehicle 1	Vehicle 2	Vehicle 3
VIN:
Year:
Make:
Model:
Weekly miles driven:
Annual miles driven:
Driven to work:	Yes No	Yes No	Yes No
Is car used for business:	Yes No	Yes No	Yes No
If driven to work or school, how many miles one way:

Information about accidents in the last 3 years:
	Event 1	Event 2	Event 3
Which driver :
Date of event:
Were you at fault:	Yes No	Yes No	Yes No

Information about the coverages you want:
	Vehicle 1	Vehicle 2	Vehicle 3
Liability (bodily injury & property damage) example 50/100/50:
Uninsured motorist protection (per event and total coverage) example 50/100:
Property damage (your car value):
Personal injury protection (medical):
Comprehensive (fire, theft, vandalism) deductible amount:
Collision deductible (amount you pay if at fault and you want your car repaired):

	Questions/comments?

	Thank you for your inquiry to the Don Gregory Agency!

DON GREGORY AGENCY, INC.
1048 W. JAMES, SUITE 103
KENT, WA 98032
TEL (253) 854-3021
FAX (253) 854-0157
E-MAIL
Or E-MAIL

INSURANCE CLAIMS - 27 hours a day, 7 days a week, CALL: 1-800-435-7764 OR USE ONLINE CLAIM FORM

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