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Great! Number of Vehicles:

One Vehicle
Two Vehicles
Three Vehicles
Four Vehicles
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Currently Insured:

Yes
No
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What year is your vehicle?

For Vehicle One

["1982","1983","1984","1985","1986","1987","1988","1989","1990","1991","1992","1993","1994","1995","1996","1997","1998","1999","2000","2001","2002","2003","2004","2005","2006","2007","2008","2009","2010","2011","2012","2013","2014","2015","2016","2017","2018","2019","2020","2021","2022","2023"]
null
"2012"
  • 1982
  • 2023
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What model is your vehicle?

For Vehicle One

Vehicle model (for Vehicle One)
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What package is your vehicle?

For Vehicle One

Standard
Luxury
Sport
Other
Unsure
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What year is your vehicle?

For Vehicle Two

["1982","1983","1984","1985","1986","1987","1988","1989","1990","1991","1992","1993","1994","1995","1996","1997","1998","1999","2000","2001","2002","2003","2004","2005","2006","2007","2008","2009","2010","2011","2012","2013","2014","2015","2016","2017","2018","2019","2020","2021","2022","2023"]
null
"2012"
  • 1982
  • 2023
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What model is your vehicle?

For Vehicle Two

Vehicle model (for Vehicle Two)
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What package is your vehicle?

For Vehicle Two

Standard
Luxury
Sport
Other
Unsure
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What year is your vehicle?

For Vehicle Three

["1982","1983","1984","1985","1986","1987","1988","1989","1990","1991","1992","1993","1994","1995","1996","1997","1998","1999","2000","2001","2002","2003","2004","2005","2006","2007","2008","2009","2010","2011","2012","2013","2014","2015","2016","2017","2018","2019","2020","2021","2022","2023"]
null
"2012"
  • 1982
  • 2023
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What model is your vehicle?

For Vehicle Three

Vehicle model (for Vehicle Three)
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What package is your vehicle?

For Vehicle Three

Standard
Luxury
Sport
Other
Unsure
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What year is your vehicle?

For Vehicle Four

["1982","1983","1984","1985","1986","1987","1988","1989","1990","1991","1992","1993","1994","1995","1996","1997","1998","1999","2000","2001","2002","2003","2004","2005","2006","2007","2008","2009","2010","2011","2012","2013","2014","2015","2016","2017","2018","2019","2020","2021","2022","2023"]
null
"2012"
  • 1982
  • 2023
back

What model is your vehicle?

For Vehicle Four

Vehicle model (for Vehicle Four)
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What package is your vehicle?

For Vehicle Four

Standard
Luxury
Sport
Other
Unsure
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What is the primary use of the vehicle?

Commute To/From Work
Commute To/From School
Pleasure
Business Individual
Business Corporate
Government
Farm
Not Listed
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How many miles each way to work?

0-3 Miles
4-5 Miles
6-9 Miles
10-19 Miles
20-49 Miles
50+ Miles
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How many miles a year?

0-5,000 Miles
5,001-7,500 Miles
7,501-10,000 Miles
12,501-15,000 Miles
15,001-18,000 Miles
18,001-25,000 Miles
25,001-50,000 Miles
50,001+ Miles
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Do you own a home?

Own
Rent
Other
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What kind of security system does the vehicle have?

No Alarm
Audible Alarm
Lojack
OnStar
Teletrac
Not Listed
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Where is the vehicle parked overnight?

Street
Carport
Garage
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Is the vehicle leased?

Yes
No
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How many doors does the vehicle have?

2 Doors
3 Doors (hatchback)
4 Doors
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Have you had any tickets or incidents?

(check any that apply)

No Incidents
Ticket - Speeding
Ticket - Other
Ticket - Alcohol
Accidents
Claims
License Suspension
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What is the comprehensive deductable amount?

$100
$250
$500 (most common)
$1,000
No coverage
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What is the collision deductible amount?

$100
$250
$500 (most common)
$1,000
No coverage
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How many drivers will be on this quote?

One Driver
Two Drivers
Three Drivers
Four Drivers
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What is the primary drivers gender?

Male
Female
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What is the primary drivers marital status?

Married
Single
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What is the primary driver's birthdate?

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What is the primary drivers work status?

Employed
Government
Housewife/Husband
Retired
Student Living w/ Parents
Stud. Not Living w/ Parents
Unemployed
Military
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What is your education level?

None or Incomplete
Diploma or GED
College w/ No Diploma
Associate Degree
Bachelor Degree
Master Degree
PhD Degree
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What is your license status?

Current
Expired
Permit
Suspended
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What is your home address?

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What is your full name?

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What is your email address?

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What is your phone number?

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