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Car Insurance Quotation Form
Car Insurance Quotation Form
Desired Effective Date for Quote:
*
Name Driver #1
*
First
Middle Initial
Last
Date of Birth Driver #1:
*
MM slash DD slash YYYY
Driver’s License Number and State Driver # 1:
*
Approximate Date first licensed in the US:
*
Sex Driver #1:
*
Male
Female
Non-Binary
Relationship Status Driver #1:
Single
Married
Separated
Divorced
Widowed
Occupation & Highest Level of Education Driver #1:
*
Best Phone #:
*
E-mail Address:
*
Residence Address:
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Prior Address if less than 3 years at current address:
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Number of years at this address:
*
Drivers
Number Of Drivers
*
1
2
3
4
5
6
7
8
9
10 or more
Name Driver #2
First
Middle Initial
Last
Date of Birth Driver # 2:
MM slash DD slash YYYY
Driver’s License Number and State Driver # 2:
Approximate Date first licensed in the US:
Sex Driver # 2:
Male
Female
Non-Binary
Relationship Status Driver # 2:
Single
Married
Separated
Divorced
Widowed
Occupation & Highest Level of Education Driver #2:
Name Driver #3
First
Middle Initial
Last
Date of Birth Driver # 3:
MM slash DD slash YYYY
Driver’s License Number and State Driver # 3:
Approximate Date first licensed in the US:
Sex Driver # 3
Male
Female
Non-Binary
Relationship Status Driver # 3
Single
Married
Separated
Divorced
Widowed
Occupation & Highest Level of Education Driver #3:
Name Driver #4
First
Middle Initial
Last
Date of Birth Driver # 4:
MM slash DD slash YYYY
Driver’s License Number and State Driver # 4:
Approximate Date first licensed in the US:
Sex Driver #4:
Male
Female
Non-Binary
Relationship Status Driver # 4:
Single
Married
Separated
Divorced
Widowed
Occupation & Highest Level of Education Driver #4:
Name Driver #5
First
Middle Initial
Last
Date of Birth Driver #5:
MM slash DD slash YYYY
Driver’s License Number and State Driver #5:
Approximate Date first licensed in the US:
Sex Driver #5:
Male
Female
Non-Binary
Relationship Status Driver # 5:
Single
Married
Separated
Divorced
Widowed
Occupation & Highest Level of Education Driver #5:
Current Coverage
Are You Currently Insured
*
Yes
No
Current Insurance Provider Name & Length of Time You’ve Maintained Continuous Insurance with this Company
*
Current Auto Bodily Injury Liability Limits
*
$30,000 per person/ $60,000 each accident
$50,000 per person/ $100,000 each accident
$100,000 per person/ $300,000 each accident
$250,000 per person/ $500,000 each accident
Other
Vehicles
Number Of Vehicles
*
1
2
3
4
5
6
7
8
9
10 or more
Year, Make, Model, VIN, and Approximate Month and Year Purchased for all vehicles:
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Vehicle #1: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
*
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Vehicle #2: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Vehicle #3: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Vehicle #4: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Vehicle #5: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Vehicle #6: Commute Mileage Driven 1 Way, Annual Mileage, & Primary Driver of this Vehicle
Business Use?
Yes
No
Is the vehicle used for uber, lyft, uber eats, amazon fresh, grub hub, or any other sort of rideshare/delivery program
Yes
No
Please List incident dates and provide details regarding any tickets or accidents in the past 5 years:
Current Monthly Premium
Any other details to ensure accurate quoting?
Any additional details to share to ensure accurate quoting? For instance, are any of your drivers full-time students with B or better GPAs? Are any of your drivers students that live away at college? If so, please provide the name of the school.
If you would like an Erie Life Insurance price indication, please provide the following:
Name
Height
Weight
Nicotine Use
Yes
No
For a more accurate quote, please complete the Life Quote Form on our website from the Insurance Services dropdown list.
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Phone
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