Name		Spouse
Driver's License Number		Driver's License Number
Address
City		State	ZIP
Home Phone		Work Phone
E-Mail Address		Current Auto Insurance Company
Renewal Date (if known)		Own Home?	Yes    No
Number of People in Household		Licensed Drivers in Household
Do you have medical coverage?	Yes    No
Do you have disability coverage?	Yes    No

#	Year	Make	Model	2dr/4dr	Miles to Work (1-way)	Annual Mileage	Comprehensive Deductible	Broad Collision Deductible	Towing / Labor	Loss of Use?
1							$250$100$500	$500$250$1000	YesNo	YesNo
	VIN#:
2							$250$100$500	$500$250$1000	YesNo	YesNo
	VIN#:
3							$250$100$500	$500$250$1000	YesNo	YesNo
	VIN#:
4							$250$100$500	$500$250$1000	YesNo	YesNo
	VIN#:

Insurance companies want to know about every licensed driver in the household.
If you have more than three, give the additional information on drivers in the comment section.

#	Driver's Name	Date of Birth	Gender	Marital Status	Moving Violations (last 3 yrs)	Accidents (last 3 yrs)
1			MaleFemale	MarriedSingleDivorced	01234+	01234+
2			MaleFemale	MarriedSingleDivorced	01234+	01234+
3			MaleFemale	MarriedSingleDivorced	01234+	01234+

Bodily Injury	Property Damage	<- or ->	Single Limit
$25000/$50000$50000/$100000$100000/$300000$250000/$500000	$25000$50000$100000$500000		$50000$100000$300000$500000

Many people prefer to fax us a copy of their current policy deck sheets.
Some send them as an e-mail attachment. If you wish, please do so. It
makes our quote more accurate. Be sure to send both sides. Our 24-hour
fax is (517) 546-9943. We also have group discounts. If you belong to
an alumni group or you or your spouse is eligible to join one, let us know.
Some other groups (often based on employment) offer discounts.
Ask us if your group is included.

Please click on the Submit button to send your estimate request.
This is not an application for insurance, and it does not obligate
this agency to issue any policy of insurance.

Our estimate will include broad collision. Basic collision can save you premium dollars.