Auto Insurance Quote Form

  • For the fastest and most accurate insurance quote, please fill in as much information possible in the form below.
  • When you are finished, click on the "Submit" Button to transmit your form to Strickler Insurance.
  • This information will be kept confidential and will be used for quote purposes only!

General Information
Name
Phone Number
Address
City State Zip
Email Address
(By entering your e-mail address address, we'll be able to keep track of any information you've already entered should you be disconnected for any reason.)
Current Carrier
Expiration Date
Number of years insured with Current Carrier
Do you own your home or do you rent?Own Rent
Years at current residence:
Number of accidents for ALL drivers (regardless of fault) in the past 3 years.
Number of violations for ALL drivers in the past 3 years.
Number of Comprehensive (Fire, theft, vandalism, glass) claims in the past 3 years.
 
Current Auto Insurance Company (not agency):
Company Name:
Policy Exp. Date: / /
Premium: $
Term: 6 Months   1 Year   Other  

Vehicle Information
Number of Vehicles:
For more than 2 Vehicles submit a 2nd Form with just your name and additional vehicle information.
Vehicle #1
Year 
Make 
Model 
> Body Type  		Vehicle #2
Year 
Make 
Model 
> Body Type 
Vehicle Use: Business Pleasure
To/from work miles one way.
Vehicle Garage Location: 		Vehicle Use: Business Pleasure
To/from work miles one way.
Vehicle Garage Location:
Vehicle Credits:
Airbag
Anti-Theft Device
Passive Restraint (Automatic Seatbelt) 		Vehicle Credits:
Airbag
Anti-Theft Device
Passive Restraint (Automatic Seatbelt)
Vehicle primarily
driven by:  		 Vehicle primarily
driven by:  
Policy Limits
Comprehensive Deductibles: Collision Deductible:
Towing Limit: Rental Reimbursement Limit:
Current Liability and Property Damage Limits:
or Combined Single Limit:
Uninsured/Underinsured Motorists Liability:
Do you have Stacked Limits for Uninsured/Underinsured Motorists?
Yes No

First Party Benefit Coverage
Medical Expense Benefit: Work Loss Benefit:
Funeral Benefit: Accidental Death Benefit:
Extraordinary Medical Benefits:
Combination First Party Benefit Coverage Options:
Tort Option: Full Limited

Driver Information
Number of drivers in household:
For additional drivers, fill out a 2nd form with your name and additional driver information
Driver #1 Driver #2
First Name    
Middle Initial    
Last Name
Date of Birth:
Sex Male
Female		 Male
Female
Marital Status     
Occupation     
Number of years with current employer    
Social Security #     
Driver's License #      
Date Licensed:
Defensive Driver Course 55 Alive
Student Driver Training		 55 Alive
Student Driver Training
Student over 100 miles away without vehicle? Yes
No		 Yes
No
 Has driver had an accident (regardless of fault) in past five years? Yes
No		 Yes
No
If yes:

Date of Accident:

Please provide brief description:

Amount Paid:

Date of Accident:

Please provide brief description:

Amount Paid:
Violations in
past 5 years		 Yes
No		 Yes
No
If yes:

 Date of Violation:

Please provide brief description:

 Date of Violation:

Please provide brief description:
Has your license ever been suspended or revoked?  Yes
No		 Yes
No
If yes:

Date:

Reason for suspension/revocation:

Date:

Reason for suspension/revocation:
Additional Comments:
Please give any additional comments about the coverage you desire: (optional)