Auto Quote

Contact Information
Name
Address
City,St,Zip
Home Phone - Best Time to Call
Work Phone -
Fax Phone -
E-Mail
Number of Drivers     Vehicles
Current Insurer
Does your policy renew within 10 days? Yes No
Resident Status

 
Driver Data (Oldest to Youngest)
1. First Name   Age Sex 
1. Martial Status  
1. Record (Number of) DUI Accidents Tickets
2. First Name   Age Sex 
2. Martial Status  
2. Record (Number of) DUI Accidents Tickets
3. First Name   Age Sex 
3. Martial Status  
3. Record (Number of) DUI Accidents Tickets
4. First Name   Age Sex 
4. Martial Status  
4. Record (Number of) DUI Accidents Tickets

 
Limits of Liability Requested
Limits Per Person / Per Occurrence / Property Damage
State Minimum 12.5 / 25 / 7.5 25 / 50 / 25
  50 / 100 / 50 100 / 300 / 100
  250 / 500 / 100  

 
Deductibles
Comprehensive Zero     $250      Do Not Include Do Not Include
  $100 $500 
Collision $100 $500  
  $250 Do Not Include

Towing Coverage Requested?    Yes     No
 

Vehicle Data
Vehicle #1  
1. Year   Annual Miles Driven
1. Make/Model/Body
1. Number of Cylinders   4wd   Alarm
1.  Airbag          ABS
1.  Vehicle Use
Vehicle #2  
2. Year   Annual Miles Driven
2. Make/Model/Body
2. Number of Cylinders   4wd   Alarm
2.  Airbag          ABS
2.  Vehicle Use
Vehicle #3  
3. Year   Annual Miles Driven
3. Make/Model/Body
3. Number of Cylinders   4wd   Alarm
3.  Airbag          ABS
3.  Vehicle Use
Vehicle #4  
4. Year   Annual Miles Driven
4. Make/Model/Body
4. Number of Cylinders   4wd   Alarm
4.  Airbag          ABS
4.  Vehicle Use
 
Have any of the above drivers had a suspended license in the past 5 years?

If Yes, Do you need an SR-22 Form?  

 

Questions/Comments


 

Diversified Insurance Services
253 E. Church St.
Marion, OH 43302
740-382-9343		 100 E. Lima St.
Forest, OH 45843
419-273-2534

1-800-589-2534
(Elsewhere in Ohio Only, Please)