IIG - Auto Quote

independent insurance group - auto quote

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North Carolina, South Carolina, Georgia and Virginia Residents Only!

Let us quote your auto insurance needs! You may give us a call or complete the following form to receive a competitive quote.

Contact Information...
Name (required)
Address
Address (second line)
City		State	Zip

Please Contact Me Via...	Phone E-Mail Fax
Work Phone		Best Time To Call
Home Phone		Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

Car	Year	Make	Model (e.g., Civic, Taurus, Sentra ...)	Body Style	VIN Vehicle Identification #	No. of Cylinders
Your Vehicles...
1
2
3
4

Car	Is car driven to work or school?	Is car used in business? (excluding to and from work)
1	Yes No	Yes No
2	Yes No	Yes No
3	Yes No	Yes No
4	Yes No	Yes No

Discounts
Car 1	Car 2	Car 3	Car 4
Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint	Driver Airbag Passenger Airbag Passive Restraint
Daytime Lights	Daytime Lights	Daytime Lights	Daytime Lights
Anti-lock Brakes	Anti-lock Brakes	Anti-lock Brakes	Anti-lock Brakes
Active Anti-theft Passive Anti-theft Electronic Tracking VIN Etching	Active Anti-theft Passive Anti-theft Electronic Tracking VIN Etching	Active Anti-theft Passive Anti-theft Electronic Tracking VIN Etching	Active Anti-theft Passive Anti-theft Electronic Tracking VIN Etching

Your Coverage Options (applies to all vehicles on the policy)
Bodily Injury	(per individual, per incident)
Property Damage
Medical Coverage
Combined Uninsured and Underinsured Motorists	(per individual, per incident)

Car	Collision Deductible	Comprehensive Deductible	Transportation Option	Towing (per incident)
Deductibles and Coverage Options
1
2
3
4

Driver	Name	Date of Birth (MM/DD/YYYY)	Sex	Marital Status	State Licensed
Your Drivers
1			F M
2			F M
3			F M
4			F M

Driver	Driver Status	Number of Years Licensed
1	Principal Occasional	yrs
2	Principal Occasional	yrs
3	Principal Occasional	yrs
4	Principal Occasional	yrs

Incident	Driver Involved	Ticket / Violation	Violation Date (MM/DD/YYYY)
Accidents and Ticket Information
1
2
3
4
5
6
7
8

Comments, Questions, or Concerns

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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