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INSURANCE MADE EASY©

Automobile Insurance COVER YOUR WORLD Automobile Insurance

COVER YOUR WORLD

 
 

Allen/Freeman/McDonnell Agency

will be happy to quote your

AUTOMOBILE INSURANCE.

Be advised that we are only licensed to provide insurance in Maine and New Hampshire. Please answer each question that follows and then send the form to us over the net. We will try to contact you within 24-hours. Thanks for considering

Allen/Freeman/McDonnell Agency.


Information About You

This form is for Maine and New Hampshire residents only.
If you will be moving to Maine in the near future click here.

First Name:* Middle Initial or Name:
Last Name:*
Address:*
City:* State:* Zip Code:*
Phone:* FAX:
E-Mail:*
Please Retype Email Address;
E-Mail:*
How do you wish to be contacted?*

Auto Insurance Request

Marital Status:
Present insurance company?* For How Long? yrs
Policy Renewal Date?
Driver Information About You and Your Family
Driver 1* Driver 2 Driver 3 Driver 4
Driver Name*
ME License*
Driver Sex*
Driver Date
of Birth*
Number of
tickets last
3 years*
Number
of accidents
last 3 years*
Years
Licensed*
Daily 1 Way
Commute*		 mi mi mi mi

Information About Your Vehicles

Vehicle1* Vehicle2 Vehicle3 Vehicle4
Year*
Make*
Model*
Used for
Business*
Total
Annual Miles*
VIN# **
** If you choose not to or cannot provide the Vehicle Identification Number (VIN#), please be advised that some of our companies may not be able to provide you with a Quote at this time.

BI/PD
Liability Limit*
$
$
$
$

Comprehensive Ded.*
$
$
$
$

Collision Ded.*
$
$
$
$

Medical Pay*
$
$
$
$

Towing & Labor*
$
$
$
$

Rental*
$
$
$
$
Does any driver need an SR-22 filing?*
If "YES", which driver needs the filing?

If any drivers have had tickets or accidents in the last 3 years please provide details below on which driver(s) have received them, what the violation was, the dates involved and details about any accidents (including who was at fault and the approximate amount paid):


How did you find our web site?


Thanks for your request! Just click on the SEND button below to send it to us! NOTICE: Please be advised that insurance coverage cannot be changed or bound by submitting or leaving an electronic message or voice mail message.

Allen/Freeman/McDonnell Agency

or its parent company, Insurance Made Easy, Inc. does not resell or distribute your personal information in any form. We use the information from this form exclusively to try to provide you the insurance coverages which you are requesting. In completing this form, you give us premission to telephone you, if needed.



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