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Car Insurance | Auto Insurance
Request an Auto Quote

Today is:
 
At Moulthrop-Clift, we're committed to service.  That's why we've developed a simple and convenient way to request an Automobile Quote.  Simply fill out the below form with as much information as possible.  You will receive a reply as soon as possible during normal business hours.
Personal/Policy Information Name: 
Address: 
City:      State:      Zip: 
Phone:      Fax:      Cell: 
Email Address: 

Policy Information Will the vehicles be garaged at this location?  Yes   No
How many members are in the household?  1   2   3   4   5   6
Have you had continuous coverage (no lapse or cancellations for a full previous 6 months)?  Yes   No
Present Company: 
Policy Expiration Date:
What are the lowest liability limits on your policy?  20,000/40,000   50,000/100,000   100,000/300,000   250,000/500,000   Other, Please list: 

Do you have primary health insurance that will cover you in an auto accident?  Yes   No
Do you own your home?  Yes   No
When would you need this coverage effective?
Would any of the vehicles be used for business?  Yes   No

Vehicle Information

Vehicle #1
Year:     Make:     Model: 
VIN Number: 
Will this car be used for:  Commute   Pleasure   Farm   Business

Choose Liability Limits:  20,000/40,000   50,000/100,000   100,000/300,000
250,000/500,000   Other, Please list: 

Comprehensive Deductible:  None   0   100   250   500
Collision Deductible:   None  100   250   500     Form: 
Towing Coverage:  Yes   No
Rental Coverage:  Yes   No

Vehicle #2
Year:     Make:     Model: 
VIN Number: 
Will this car be used for:  Commute   Pleasure   Farm   Business

Choose Liability Limits:  20,000/40,000   50,000/100,000   100,000/300,000
250,000/500,000   Other, Please list: 

Comprehensive Deductible:  None  0   100   250   500
Collision Deductible:   None   100   250   500     Form: 
Towing Coverage:  Yes   No
Rental Coverage:  Yes   No

Vehicle #3
Year:     Make:     Model: 
VIN Number: 
Will this car be used for:  Commute   Pleasure   Farm   Business

Choose Liability Limits:  20,000/40,000   50,000/100,000   100,000/300,000
250,000/500,000   Other, Please list: 

Comprehensive Deductible:  None   0   100   250   500
Collision Deductible:   None   100   250   500     Form: 
Towing Coverage:  Yes   No
Rental Coverage:  Yes   No

Vehicle #4

Year:     Make:     Model: 
VIN Number: 
Will this car be used for:  Commute   Pleasure   Farm   Business

Choose Liability Limits:  20,000/40,000   50,000/100,000   100,000/300,000
250,000/500,000   Other, Please list: 

Comprehensive Deductible:  None   0   100   250   500
Collision Deductible:   None   100   250   500     Form: 
Towing Coverage:  Yes   No
Rental Coverage:  Yes   No
Driver Information (Please list all household drivers)

Driver #1
First Name:       Last Name: 
Date of Birth:     Driver's License Number: 
Sex:  Male   Female     Status:  Single   Married

Does this driver have any tickets or accidents in the past five years?  Please list below.
Violation:        Date: 
Violation:        Date: 
Violation:        Date: 
How many claims has this driver had over $1,000?  0   1   2   3

Driver #2
First Name:       Last Name: 
Date of Birth:     Driver's License Number: 
Sex:  Male   Female     Status:  Single   Married

Does this driver have any tickets or accidents in the past five years?  Please list below.
Violation:        Date: 
Violation:        Date: 
Violation:        Date: 
How many claims has this driver had over $1,000?  0   1   2   3
Additional Information Please list any additional vehicles, drivers, or comments below:
Contact Information
How do you wish to be contacted? 
Coverage Notice Please check here, stating that you agree that no coverage is bound or changed until you receive confirmation from us.