Auto Insurance - McClure and Associates Insurance Specialists, Inc.

Auto Insurance Quote

Personal Information:
Name:
Address:
City:
State:	Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Day Phone:
Night Phone:
Best Time To Call:	AM PM
Email Address:
Occupation:
How long at current employer:

Current Insurance Information
Company Name
Expiration Date:
Premium Amount:
Amount Insured For:
Policy Term:	6 Months 1 Year Other



Vehicle Information
Year of Vehicle:
Make of Vehicle:
Model of Vehicle
Vehicle ID Number
Usage of Vehicle	Work Pleasure Farm Business If work how many miles?

Year of Vehicle:
Make of Vehicle
Model of Vehicle
Vehicle ID Number
Usage of Vehicle	Work Pleasure Farm Business If work how many miles?

Coverages
Bodily Injury:	25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000
Property Damage:	25,000 50,000 100,000 250,000
Medical Payments:	None 1,000 5,000 10,000
Uninsured Motorists:	25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000
Comprehensive:	None 100 250 500 1000
Collision	100 250 500 1000


Driver Information
Name
Date of Birth:
Driver's License Number:
Social Security Number:
Marital Status	Single Married
Any Tickets in the last 5 years?: If yes When? What Happened?	Yes No
Any Accidents in the last 5 years?: If yes When? What Happened?	Yes No
Any claims in the last 5 years?: If yes When? What Happened?	Yes No

Name
Date of Birth:
Driver's License Number:
Social Security Number :
Marital Status	Single Married
Any Tickets in the last 5 years? : If yes When? What Happened?	Yes No
Any Accidents in the last 5 years?: If yes When? What Happened?	Yes No
Any claims in the last 5 years?: If yes When? What Happened?	Yes No


Additional Comments:

McClure & Associates Insurance Specialists, Inc.
420 N. Chestnut Avenue Oconto Falls, WI 54154
Tel 920.848.4000 Fax 920.848.4001