Automotive Quote

Celebrating over 150 continuous years of service to
Marshall Michigan, and the State of Michigan

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On-Line Auto Insurance Quote Form One simple Form - Takes only a few minutes to fill out Your Personal Data
Your Name
Street Address
City:
State:	Michigan!
Zip Code
E-Mail (Required)
E-Mail again for accuracy
Phone Number
Fax (optional)
Marital Status: Single Married	Homeowner? Yes NO

Currently Insured? (If Yes, list carrier, and # of years continuous. If none, type N/C

Driver Information #1
Name		Birth date
Gender (M/F)		Drivers License #

Be Specific to tell if accidents are "at-fault" or "Not at-fault" - Carriers require proof on Not-at-fault accidents); Also, be specific as to TYPE of citations, and approximate DATES of each in the field below:

Number & Type of MAJOR Accidents last 3 years:
Number & Type of MINOR Accidents last 3 years:
Number & Type of MAJOR Citations last 3 years:
Number & Type of MINOR Citations last 3 years:
Daily Commute ONE WAY Miles:

Driver Information #2
Name		Birth date
Gender (M/F)		Drivers License #

Number & Type of MAJOR Accidents last 3 years:
Number & Type of MINOR Accidents last 3 years:
Number & Type of MAJOR Citations last 3 years:
Number & Type of MINOR Citations last 3 years:
Daily Commute ONE WAY Miles:

Vehicle #1 Information (If "Non-Owners", type "NON-Owner in "Year" Field)
VIN # of Vehicle:		Year, Make & Model:
Annual Mileage:		Used in business? (explain, if Yes)
VEHICLE #1 COVERAGE'S
Limits of Liability:	$20/40 BI / 10 PD $50/100 BI /50 PD $100/300 BI / 50 PD Other Coverage Needed

Comprehensive & Collision:	$250 Deductible $500 Deductible $1000 Deductible Other Coverage Needed

Do you want Medical Coverage?	Yes No
Uninsured Motorist Cov.?	Yes No

Vehicle #2 Information (If "Non-Owners", type "NON-Owner in "Year" Field)
VIN # of Vehicle:		Year Make & Model:
Annual Mileage:		Used in business? (explain, if Yes)
VEHICLE #2 COVERAGE'S
Limits of Liability:	$20/40 BI / 10 PD $50/100 BI /50 PD $100/300 BI / 50 PD Other coverage Needed

Comprehensive & Collision:	$250 Deductible $500 Deductible $1000 Deductible Other Coverage Needed

Do you want Medical Coverage?	Yes No
Uninsured Motorist Cov.?	Yes No

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Sullivan Insurance Agency, Inc.
140 W. Michigan Ave.
Marshall, MI 49068
Phone: 269-781-8909
Fax: 269-781-3535