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Peterson Insurance: Auto Quote
Questions marked by * are required.
1.
Hello! We wanted to let you know that your information is PRIVATE and will not be sold to third parties. We are asking for your PRIVATE information in order to obtain the best possible quote for you. Please look for the secure forms icon in your browser before completing any online forms. If you have any questions, please don't hesitate to contact us at 574-234-2464. Thank you for the opportunity to earn your business. Please indicate your preferred method of contact. Sincerely, Peterson Insurance Agency.
Email
Mail
Phone
2.
Name *
3.
Email *
4.
Phone
5.
Address
6.
City / State / Zip
7.
Current Auto Insurance Company
8.
Current Auto Insurance Company Expiration Date
9.
Vehicle #1- Year/Make/Model/VIN
10.
Liability Limits
25/50/10
50/100/50
100/300/100
250/500/100
Other- see notes below
11.
Vehicle #1 - Comprehensive
No Comp coverage
100 deductible
250 deductible
500 deductible
1,000 deductible
Other - see notes below
12.
Vehicle #1 - Collision
No Collision coverage
100 deductible
250 deductible
500 deductible
1,000 deductible
Other - see notes below
13.
Vehicle #2- Year/Make/Model/VIN
14.
Vehicle #2 - Comprehensive
No Comp coverage
100 deductible
250 deductible
500 deductible
1,000 deductible
Other - see notes below
15.
Vehicle #2 - Collision
No Collision coverage
100 deductible
250 deductible
500 deductible
1,000 deductible
Other - see notes below
16.
Towing Coverage
Yes
No
17.
Rental Coverage
Yes
No
18.
Driver #1 - Name (First/Middle/Last)
19.
Driver #1 - Date of Birth (mm/dd/yr)
20.
Driver #1 - License Number
21.
Driver #1 - Social Security Number
22.
Driver # 1 - Gender
Male
Female
23.
Driver # 1 - Marital Status
Single
Married
Divorced
Widowed
24.
Driver #1 - Driving Record
EXCELLENT - No Tickets or Accidents in the last 5 years
GOOD - 1 ticket within the last 5 years and no accidents
FAIR - No more than 1 ticket and accident within last 5 years
Other (Please describe in comments section below)
25.
Driver #2 - Name (First/Middle/Last)
26.
Driver #2 - Date of Birth (mm/dd/yr)
27.
Driver #2 - License Number
28.
Driver #2 - Social Security Number
29.
Driver #2 Gender
Male
Female
30.
Driver #2 Marital Status
Single
Married
Divorced
Widowed
31.
Driver #2 Driving Record
EXCELLENT - No Tickets or Accidents in the last 5 years
GOOD - 1 ticket within the last 5 years and no accidents
FAIR - No more than 1 ticket and accident within last 5 years
Other (Please describe in comments section below)
32.
Additional Vehicle(s) Info
33.
Additional Driver(s) Info
34.
Additional information
35.
Please note:
Please remember coverage CANNOT be bound over electronic communications. You must speak with a representative of the Agency. For immediate assistance don't hesitate to call us at 574.234.2464.
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email
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phone
Main-574.234.2464
Fax-574.289.1257
Toll-877.237.4346
address
2516 Mishawaka Ave
South Bend IN 46615
Talk To Your Agent
AUTO
HOME
BUSINESS
LIFE
HEALTH
VIDEOS
Best insurance agent in town
New Auto Security Video
Rate Lock Video
Scheduled Coverage Video
MORE
ABOUT US
BROCHURES
BLOG
CLAIMS
CONTACT US
DISCLAIMER
PAYMENTS
PICTURES
PRIVACY
QUOTES
TESTIMONIALS