AUTO QUOTE FORM

Our Service area is Eastern Washington. And if You have Insurance needs, and want great "Service that Makes a Difference", then we invite you to complete the Auto quote below. Hit submit, and it will be sent directly to us, and a representative will contact you with the results of the quote.

PERSONAL INFORMATION

Name:
Address:
City:
County:
State:
Zip Code:
E-Mail Address:
Phone Number
Fax Number
Current Insurance Company:
Expiration Date:
Policy #

DRIVER INFORMATION

Driver 1

Driver 1 Name:
Driver 1 Occupation:
Driver 1 Date of Birth:
Driver 1 Sex:

Driver 2

Driver 2 Name:
Driver 2 Occupation:
Driver 2 Date of Birth:
Driver 2 Sex:

Driver 3

Driver 3 Name:
Driver 3 Occupation:
Driver 3 Date of Birth:
Driver 3 Sex:

Driver 4

Driver 4 Name:
Driver 4 Occupation:
Driver 4 Date of Birth:
Driver 4 Sex:

Have any of the above listed drivers had any accidents or moving
violations in the past 3 years?

If you answered yes to the above question, please fill in the DATE, DRIVER NAME and DESCRIPTION of violation and or accident in the text box below.

VEHICLE INFORMATION

  Year Make Model #of doors Principle Driver
(1,2,3, or 4)
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
 

COVERAGE INFORMATION

Liability Limits

Please choose a liability limit & property damage limit from the limits listed below. Limits will be the same for all vehicles.

UnInsured/UnderInsured Motorist Protection

Please check if you desire Un/UnderInsured Motorist Coverage. Please note that limit for Un/UnderInsured Motorist Protection will be the same as the liability limit you selected above. If you do not desire this coverage, a rejection form must be signed.

Personal Injury Protection/Medical Payments

Please check if you would like Personal Injury Coverage/Medical Payments.

If you check "Yes", please choose an amount

Comprehensive Coverage

Comprehensive Covers your vehicle for: Hail, Fire, Theft, Animal Collision and other losses not covered by Collision.

Vehicle 1

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 2

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 3

Comprehensive Coverage If Yes, Choose Deductible

Vehicle 4

Comprehensive Coverage If Yes, Choose Deductible

Collision Coverage

Collision Covers damage to your vehicle if your in an accident and its your fault.

Vehicle 1

Collision Coverage If Yes, Choose Deductible

Vehicle 2

Collision Coverage If Yes, Choose Deductible

Vehicle 3

Collision Coverage If Yes, Choose Deductible

Vehicle 4

Collision Coverage If Yes, Choose Deductible

Towing Coverage

Do you desire Towing Coverage

Rental Coverage

Do you desire Rental Coverage

Thank you for completing our online quote form. We will respond with a quote within two business days.

 

CLICK HERE FOR HOME QUOTE FORM


THANK YOU!!

CLICK HERE TO GO TO HOMEPAGE


Elliott Insurance Service, Inc.
702 North First Street
P.O. Box 1348
Yakima, Washington 98907
(509) 248-7711 or (800) 487-3369
FAX:(509) 453-3293


A member of the American relocation Network. © 1997 All rights reserved
All trademarks are owned by the respective company or AMC Internet Consultants