Home Back

MI Auto Quote

 

Home
Back

 

 

 

 


 


Kozhuharov Insurance Agency
Toll Free: (877) 205-0051
Fax: (269) 441-5163
E-mail: deyan@kozhuharovagency.com

Michigan Personal Auto Insurance Quote Request

Effective Date:
Your Name:
Your Mailing Address: Street

City                                                         State        Zip
     
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                                       Expiration Date:
  
Liability Limits and Coverages:
Please select the coverages and limits that are to apply to your vehicles.
Bodily Injury - Split Limits
 		Bodily Injury - Combined Limits
Property Damage
 		Medical Payments
Uninsured Motorists

Underinsured Motorists
 		Enter additional information/comments here:
Your Vehicles:   If you have more than four vehicles, please call our office for a quote.

 
Vehicle 1.
Year     Make and model:
  
VIN (if known):
Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
 Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Vehicle 2.
Year     Make and model:
  
VIN (if known):
Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
 Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Vehicle 3.
Year     Make and model:
  
VIN (if known):
Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
 Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
 
Vehicle 4.
Year     Make and model:
  
VIN (if known):
Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
 Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
 
Driver Information:   If there are more than four drivers, please call our office for a quote.

 
Driver 1:
Name:
DOB:           Sex:        Marital Status
         
Driver 1 Occupation:
Social Security No:  -and-  Drivers License No:
             
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 ave. or better)
 At School over 100 miles away.
 
 Driver 2:
Name:
DOB:           Sex:        Marital Status
         
Driver 2 Occupation:
Social Security No:  -and-  Drivers License No:
             
Has Driver 2 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 ave. or better)
 At School over 100 miles away.
 
Driver 3:
Name:
DOB:           Sex:        Marital Status
         
Driver 3 Occupation:
Social Security No:  -and-  Drivers License No:
             
Has Driver 3 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 ave. or better)
 At School over 100 miles away.
 		 Driver 4:
Name:
DOB:           Sex:        Marital Status
         
Driver 4 Occupation:
Social Security No:  -and-  Drivers License No:
             
Has Driver 4 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 ave. or better)
 At School over 100 miles away.
 
All Drivers:
 
If a Group Association Discount applies, please enter association below.

 		 What is the current occupation of your household's highest wage earner?


 

Additional Comments
Please use the box below to enter any additional information you feel should be considered:

We cannot bind coverage from an e-mail or voicemail request. Coverage is bound after you receive a written e-mail or telephone confirmation from an agency staff member.

If you have not received a response from us within one business day, please contact us again.

Thank you.



 

 

[ Home ] [ Back ]

Send mail to deyan@kozhuharovagency.com with questions or comments about this web site.
Copyright © 2008 Kozhuharov Insurance Agency
Last modified: 08/11/11