Did you really mean: Auto Insurance - Fleet
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Complete these questions and get a customized, timely response from prescreened and member referred Insurance Agents that are interested in working with you. You choose the Insurance Agent that best meets your needs. No Cost.
1) Do you currently have auto insurance?
Yes
No
2) How many drivers will you need insured?  [required]
3) How many vehicles will you need insured?  [required]
4) How many years has the primary driver been licensed?  [required]
5) What is your marital status?
6) What is your gender?
Male
Female
7) How many at fault accidents have you had last 3 years?  [required]
8) How many not-at-fault accidents have you had in the last five years?  [required]
9) How many moving violations have you had in the last three years?  [required]
10) What is the year, make, model and engine size of the vehicles to be insured?
11) How is the vehicle used?
Commute to/from work
Commute to/from school
Pleasure
Business Individual
Business Corporate
Government
Farm
12) How many miles do you drive annually?
13) Will you require PIP/MEDPAY coverage?
14) Will you require rental reimbursement coverage?
Yes
No
15) Will you require towing coverage?
Yes
No
16) This service is completely FREE to you, however, businesses pay a fee to participate. Please respect their time and money by submitting an accurate and serious request.  [required]
I understand a business may call to answer any questions or to setup an appointment.
17) Comments or Details:

Please provide your location.  [required]
18)
Street Address:
19)
ZIP Code:  -- OR --
City/State 

Contact Information:
20)
First Name: [required]
 Last Name: [required]
21)Email Address: [required]
22)
Day Time Phone: [required]
()-x		 Evening Phone:
()-
23)
Best Time: [required]

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