Request Auto Insurance Quote

Please complete the following information if you would like to obtain a proposal on Auto Insurance. Once received we will contact you by phone. Please understand this is not an application for insurance nor does it bind any coverage. An application will be sent to you if coverage is desired.

All of the information provided is confidential and will be used solely for the purpose of developing a proposal for you.

This proposal is designed for private passenger autos. If you have a commercial vehicle please call us to discuss and we can put a proposal together for you.

Personal Information (required)
What is your name?	First Middle Last
What is the garaging address?	Street City State ZIP
What is your telephone number?	Home Business
What is your fax number?
What is your email address?

Mailing Address
What is your mailing address? (if different from above)	Street City State ZIP

Driver Information
Driver 1	First name Last name Gender Date of birth Marital status State licensed Occupation
Driver 2	First name Last name Gender Date of birth Marital status State licensed Occupation
Driver 3	First name Last name Gender Date of birth Marital status State licensed Occupation
Driver 4	First name Last name Gender Date of birth Marital status State licensed Occupation

Vehicle Information
Vehicle 1	Year Make Model Miles per year Airbag Automatic seat belts Anti-lock brakes Anti-theft device Ownership
Vehicle 2	Year Make Model Miles per year Airbag Automatic seat belts Anti-lock brakes Anti-theft device Ownership
Vehicle 3	Year Make Model Miles per year Airbag Automatic seat belts Anti-lock brakes Anti-theft device Ownership
Vehicle 4	Year Make Model Miles per year Airbag Automatic seat belts Anti-lock brakes Anti-theft device Ownership

Violation Information
Last 3 years (minor violations) Last 5 years (major violations)
Minor violations — speeding, turn, stop sign, red light, etc.	Driver 1 Driver 2 Driver 3 Driver 4
Accidents — non-chargeable	Driver 1 Driver 2 Driver 3 Driver 4
Accidents — chargeable	Driver 1 Driver 2 Driver 3 Driver 4
Major violations — drunk driving, reckless, hit-and-run, etc.	Driver 1 Driver 2 Driver 3 Driver 4

Coverage Information
Personal liability	Bodily Injury Bodily Injury
Uninsured motorist	Bodily Injury
Medical payment	Bodily Injury
Comp (theft)	Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Collision	Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4

Miscellaneous Information
Current insurance company
Expiration date
Current premium
Questions or comments

Best Time to Contact You
Please let us know the best time to call and discuss your quote	Morning Afternoon Evening Anytime
Or, please specify another time

Larkin Group — Northern Michigan Insurance and Financial Specialists located in Traverse City and Leelanau