Please complete this form in its entirety and submit via email at or via fax at 877-444-4094.

If you need assistance, please contact III at 800-444-1744

Agent Information
Agent Name:
Agent Phone: ( ) -
Agent Email:

Personal AutoInsurance Quote Request

Note to Customer (in credit states only): To provide an accurate quote, we will ask you numerous questions about yourself and your Vehicle. Aspart of the quoting process, we will also be utilizing various consumer reports which may include reports regarding your credit history. All information we acquire maybe provided to our insurance carriers. Please initial here if we have your permission to gather and share information as described herein – *Inorder to obtain quote we must have permission to run financial responsibility: Yes No Initial: __

Customer Information
Name: / Date of Birth: / SSN: - - / Phone Number: ( ) -
Address*: / City: / State: / Zip:
*Primary Residence: Own Home/Condo Own Mobile Home (10 years old or newer) Rent Live with Parents Other: ____
Email Address (5% Paperless Discount Available): / Reason for new Policy:
Prior Coverage Information
Prior Carrier: / 6 Months of Coverage without Lapse in Past 12 Months?: Yes No
Effective Dates: Start - End - / Policy #: / BI Limits:

To ensure accuracy, it is the responsibility of the agencies to obtain a current MVR on all drivers as III does not order MVR’s.

Vehicle Information / Vehicle #1 / Vehicle #2 / Vehicle #3 / Vehicle #4
Year/Make/Model / / / / / / / /
VIN
Garaging Zip code
Usage / ______Commute <10 milesCommute 10+ milesPleasureBusiness (incidental)ArtisanFarm / ______Commute <10 milesCommute 10+ milesPleasureBusiness (incidental)ArtisanFarm / ______Commute <10 milesCommute 10+ milesPleasureBusiness (incidental)ArtisanFarm / ______Commute <10 milesCommute 10+ milesPleasureBusiness (incidental)ArtisanFarm
Vehicle Used for Delivery / ____YesNo / ____YesNo / ____YesNo / ____YesNo
Antitheft / ____YesNo / ____YesNo / ____YesNo / ____YesNo
Airbag / ______Airbag-DriverAirbag-FullPassive Restraint / ______Airbag-DriverAirbag-FullPassive Restraint / ______Airbag-DriverAirbag-FullPassive Restraint / ______Airbag-DriverAirbag-FullPassive Restraint
Total Stated Value / $ / $ / $ / $
Driver Information / Driver #1 / Driver #2 / Driver #3 / Driver #4
Name
DOB and Marital Status / DOB: M or S / DOB: M or S / DOB: M or S / DOB: M or S
Social Security Number / - - / - - / - - / - -
Relationship to Insured / ______Named InsuredSpouseParentChildOther / ______Named InsuredSpouseParentChildOther / ______Named InsuredSpouseParentChildOther / ______Named InsuredSpouseParentChildOther
Driver’s LicenseState & # / State: #: / State: #: / State: #: / State: #:
Accidents in Past 35 Mo.(include dates)
Violations in Past 35 Mo.(include dates)
SR-22 Required? / ____YesNo / ____YesNo / ____YesNo / ____YesNo
Coverage Information / Vehicle #1 / Vehicle #2 / Vehicle #3 / Vehicle #4
BI/PD
UM/UIM
UMPD
PIP
Medical Payments
Comp & Collision
Rental Reimbursement
Roadside Assistance / ____YesNo / ____YesNo / ____YesNo / ____YesNo
Custom Parts / Equipment
Payoff / ____YesNo / ____YesNo / ____YesNo / ____YesNo