Mennonite Insurance Services

Auto Insurance Quote Form

For the fastest and most accurate automobile insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

* Required Fields

General Information

*Name:
*Address:
*City:
*State:
*ZIP:
* Date of Birth:
* Email:
*Daytime Phone:	( ) -
FAX:	( ) -

Yes No

* Do you currently attend a Mennonite, Brethren in Christ or Missionary Church?

Current Insurance Company (not agency):

* Company name:

* Policy exp. date (month/year):

* Policy Term:

1 year6 months Other

* Current premium:

Vehicle Information:
Car #1
Year:
Make:
Model:
Vehicle ID#:
Annual Milage:
Anti-theft/Alarm:
Zip Code where Garaged:

Coverage Information:

* Bodily Injury:		* Property Damage:
* Uninsured Motorists:		UMPD/Collision Ded. Waiver?
* Medical Payments:

* Comprehensive Deductible:		* Collision Deductible:
* Towing?		* Rental Reimbursement?

Add Car #2

No other cars

Vehicle Information:
Car #2
Year:
Make:
Model:
Vehicle ID#:
Annual Milage:
Anti-theft/Alarm:
Zip Code where Garaged:

Coverage Information:

Car #2	Comprehensive Deductible:		Collision Deductible:
Car #2	Towing?		Rental Reimbursement?

Add Car #3

No other cars

Vehicle Information:
Car #3
Year:
Make:
Model:
Vehicle ID#:
Annual Milage:
Anti-theft/Alarm:
Zip Code where Garaged:

Coverage Information:

Car #3	Comprehensive Deductible:		Collision Deductible:
Car #3	Towing?		Rental Reimbursement?

Add Car #4

No other cars

Vehicle Information:
Car #4
Year:
Make:
Model:
Vehicle ID#:
Annual Milage:
Anti-theft/Alarm:
Zip Code where Garaged:

Coverage Information:

Car #4	Comprehensive Deductible:		Collision Deductible:
Car #4	Towing?		Rental Reimbursement?

Continue

Driver Information:
Driver #1
Name:
Age:
Relationship to you:
		Male: Female:
Marital Status:
Occupation:
Years Licensed:
Car driven most often:
Convicted of any moving violation past 3 years:
If convicted, answer the following:		Date: / / Time:
If convicted, answer the following:		Type of conviction:
License Suspended or Revoked:		Suspended: Revoked:
Convicted of Driving Under the Influence:		Alcohol: Drugs:
* Involved in any accidents, in the last 5 years:
If an accident in last 5 years, answer the following:		Date: / /
If an accident in last 5 years, answer the following:		Description:
If an accident in last 5 years, answer the following:		Injuries: Yes No
If an accident in last 5 years, answer the following:		At Fault: Yes No
* Continuous Years of Prior Insurance:

If Youthful Driver: ( Under 25 Years Old )
Lives with Parents?	Yes No
Had Driver's Training?	Yes No
Student GPA Above 3.0?	Yes No
Student Living Away From Home?	Yes No

Add Driver #2

No other Drivers

Driver Information:
Driver #2
Name:
Age:
Relationship to you:
		Male: Female:
Marital Status:
Occupation:
Years Licensed:
Car driven most often:
Convicted of any moving violation past 3 years:
If convicted, answer the following:		Date: / / Time:
If convicted, answer the following:		Type of conviction:
License Suspended or Revoked:		Suspended: Revoked:
Convicted of Driving Under the Influence:		Alcohol: Drugs:
* Involved in any accidents, in the last 5 years:
If an accident in last 5 years, answer the following:		Date: / /
If an accident in last 5 years, answer the following:		Description:
If an accident in last 5 years, answer the following:		Injuries: Yes No
If an accident in last 5 years, answer the following:		At Fault: Yes No
* Continuous Years of Prior Insurance:

If Youthful Driver: ( Under 25 Years Old )
Lives with Parents?	Yes No
Had Driver's Training?	Yes No
Student GPA Above 3.0?	Yes No
Student Living Away From Home?	Yes No

Add Driver #3

No other Drivers

Driver Information:
Driver #3
Name:
Age:
Relationship to you:
		Male: Female:
Marital Status:
Occupation:
Years Licensed:
Car driven most often:
Convicted of any moving violation past 3 years:
If convicted, answer the following:		Date: / / Time:
If convicted, answer the following:		Type of conviction:
License Suspended or Revoked:		Suspended: Revoked:
Convicted of Driving Under the Influence:		Alcohol: Drugs:
* Involved in any accidents, in the last 5 years:
If an accident in last 5 years, answer the following:		Date: / /
If an accident in last 5 years, answer the following:		Description:
If an accident in last 5 years, answer the following:		Injuries: Yes No
If an accident in last 5 years, answer the following:		At Fault: Yes No
* Continuous Years of Prior Insurance:

If Youthful Driver: ( Under 25 Years Old )
Lives with Parents?	Yes No
Had Driver's Training?	Yes No
Student GPA Above 3.0?	Yes No
Student Living Away From Home?	Yes No

Add Driver #4

No other Drivers

Driver Information:
Driver #4
Name:
Age:
Relationship to you:
		Male: Female:
Marital Status:
Occupation:
Years Licensed:
Car driven most often:
Convicted of any moving violation past 3 years:
If convicted, answer the following:		Date: / / Time:
If convicted, answer the following:		Type of conviction:
License Suspended or Revoked:		Suspended: Revoked:
Convicted of Driving Under the Influence:		Alcohol: Drugs:
* Involved in any accidents, in the last 5 years:
If an accident in last 5 years, answer the following:		Date: / /
If an accident in last 5 years, answer the following:		Description:
If an accident in last 5 years, answer the following:		Injuries: Yes No
If an accident in last 5 years, answer the following:		At Fault: Yes No
* Continuous Years of Prior Insurance:

If Youthful Driver: ( Under 25 Years Old )
Lives with Parents?	Yes No
Had Driver's Training?	Yes No
Student GPA Above 3.0?	Yes No
Student Living Away From Home?	Yes No

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this automobile quote form. One of our representatives will respond to your submission as soon as possible!