Auburn Hills Auto Insurance Quotes

If you would like to receive a quote for auto insurance from our Auburn Hills insurance agency, simply fill out the form below and submit. One of our helpful agents will contact you to obtain any further information needed to supply an accurate quote.

If you have any questions, please contact us for more information about comprehensive auto coverage in Auburn Hills.

Full Name

Spouse's Full Name

Email Address

Address

City/State

Postal Code

Phone Number

Best time to call

Present Carrier

Expiration Date

How long with this Carrier?

Continually Insured Since

Car Information

Year	Make & Model	VIN	Title-Holder	Financed or Leased	Annual Miles Driven	Alarm Type
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Car Use

Pleasure, Commute, Business	If Commuting, Distance One-Way to Work or School	Garaging Location Address (if different than mailing address above)	Used for Delivery, Uber, Lyft, etc.
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Driver Information (including other drivers in household insured elsewhere)

Name	Sex	DOB	DL #	Married / Single	License State	Carrier Name
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Driver Information (All drivers to be rated)

Driver's Occupation (i.e., engineer, homemaker, student)	Employer's or School's Name and Address	Education Level
Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5

Convictions / At Fault Accidents / Comprehensive losses & Not-At-Fault Accidents in the last 5 years

Driver	Date	Details	Accidents - Amount Paid
Vehicle 1	Vehicle 1	Vehicle 1	Vehicle 1
Vehicle 2	Vehicle 2	Vehicle 2	Vehicle 2
Vehicle 3	Vehicle 3	Vehicle 3	Vehicle 3
Vehicle 4	Vehicle 4	Vehicle 4	Vehicle 4
Vehicle 5	Vehicle 5	Vehicle 5	Vehicle 5

Coverages and Limits

Each Person/ Each Accident
Bodily Injury

Each Occurance
Property Damage

Un/Underinsured Motorist

Personal Injury Protection (PIP Medical)*

** [To select Option 4, the Named Insured has qualified health coverage that is not Medicare; AND any spouse or resident relative who is excluding PIP medical has qualified health coverage.]
*** [To select Option 5, the Named Insured is enrolled in Medicaid; AND any spouse and all resident relatives have qualified health coverage, is enrolled in Medicaid, or are covered under another auto policy with PIP medical coverage.]
**** [To select Option 6, the Named Insured has coverage under both Medicare Part A and B; AND any spouse and all resident relatives have qualified health coverage or are covered under another auto policy with PIP medical coverage.]

* Qualified health coverage means either of the following:
Health and accident coverage that does not exclude or limit coverage for injuries related to auto accidents and has an annual individual deductible of $6,000 or less – OR - Coverage under both Medicare Parts A and B
Excess/Coordinated medical is available for the Unlimited, $500,000, and $250,000 options.

Indicate PIP – Medical Carrier below:

PIP - Medical Carrier

Wage/Loss Disability Carrier

Comprehensive (Damage to vehicle not caused by a collision). Indicate for each vehicle

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

No Deductible for Glass Breakage (Not all companies offer this option for an additional cost. Do you want this coverage quoted on this vehicle if available?)
Indicate for each vehicle

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Collision Deductible Indicate for each vehicle
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Collision Type
Indicate for each vehicle

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Towing Limit
Indicate for each vehicle
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Auto Rental Reimbursement
Indicate for each vehicle
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Total # of All Household Family Members including non-driving members

Group Discount (include all that apply)

Name	Membership Number
Professional Society Name	Professional Society Name
Senior Association	Senior Association
Alumni - College/University Name	Alumni - College/University Name
Bank - Credit Union	Bank - Credit Union
Other	Other

DO YOU WANT A LIFE QUOTE?
Yes, PleaseNo, Thanks

Notes to Agent

By submitting your information, you agree to the following terms:
Insurance Coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail, or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent and or your insurance company.
Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. A proposal is not an insurance policy. Please refer to the actual policy for coverage limits, definitions, and coverage exclusions.