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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

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. Agree Disagree

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