Miller-Lewis Insurance Agency, Inc.

Automobile Insurance Quote

All Information submitted is held in the Strictest Confidence and is NOT being shared with anyone outside our company nor is it being used for marketing or advertising purposes, please also note that this is NOT an application for insurance, just a request for a quote.

Depending on the information you provide, may receive a discount for the following:

Being a Good Driver
Being a Good Student
Having a Homeowner's Policy with your Auto Insurance Carrier

	* required fields
	To ensure an accurate rating, please complete information below. If you are unsure of answer, please leave it blank.
About You
Your Name	*
Address
City	State Zip
County	*
Home Phone	* Work Phone ext.#
Email Address	*
Marital Status
Residence
Occupation
Current Coverage
Current Insurance Company	*
How Long?	Policy Expires Month (exp: Jan)

Drivers Information

Drive #1

Date of Birth
Sex
Years U.S. Drivers License	yrs.
Tickets in last 5 Years	#
Accidents in last 5 Years	#

Drive #2

Date of Birth
Sex
Years U.S. Drivers License	yrs.
Tickets in last 5 Years	#
Accidents in last 5 Years	#

Drive #3

Date of Birth
Sex
Years U.S. Drivers License	yrs.
Tickets in last 5 Years	#
Accidents in last 5 Years	#

In the last 5 years has any driver listed above had any of the following:

Driver's License Suspended
Insurance Cancelled
Physical or Metal Impairment
Claim / Loss
Arrest
Bankruptcy

Please describe any checked items above, any accidents, claims or tickets, including dates:

Vehicle Information

Vehicle #1

ID/VIN
Year
Make
Model
Type
Cylinders

Main Usage

Annual Miles Driven

Comprehensive

Collision

Liability Limits

Vehicle #2

ID/VIN
Year
Make
Model
Type
Cylinders

Main Usage

Annual Miles Driven

Comprehensive

Collision

Liability Limits

Vehicle #3

ID/VIN
Year
Make
Model
Type
Cylinders

Main Usage

Annual Miles Driven

Comprehensive

Collision

Liability Limits

Credits:

Airbags
Anti Lock Brakes
Auto Seat Belts
Anti Theft Device

Additional Coverage:

Towing
Rental Car

Any additional information or 4th driver / 4th vehicles information:

Reply via:	Email Phone Mail
How did you hear of us?

Any Questions or Comments?