Commerce Group, Inc.

Auto Quote

Page 1

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If you wish to receive an accurate quote, please fill out the form completely. If you prefer you can give us your contact information only, and we will contact you by the next business day.

Driver #1 Information

First Name required

Middle Name required

Last Name required

Occupation required

Business required

Highest level of Education required

Date of Birth required

Click in box to select date

Drivers License Number required

Gender select one

Select one

Male
Female

Marital Status select one

Select from list

Moving violations in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each violation required

Accidents in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each accident required

Driver #2

First Name required

Middle Name required

Last Name required

Occupation required

Business required

Highest level of Education required

Date of Birth required

Click in box to select date

Drivers License Number required

Gender select one

Select one

Male
Female

Marital Status select one

Select from list

Moving Violations in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each violation required

Accidents in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each accident required

Driver #3 required

First Name required

Middle Name required

Occupation required

Business required

Highest level of education required

Date of Birth required

Click in box to select date

Drivers license number required

Gender select one

Select one

Male
Female

Marital Status select one

Select from list

Moving violations in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each violation required

Accidents in the last 5 years select one

Select one

0
1
2
3

Please provide the date and a brief description of each accident required

Page 2

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Address


Address

Address Line 2

City	State	Zip Code

Home Phone required

Phone Number

Work Phone required

Phone Number

Email required

Email Address

Do you currently have insurance? select one

Select one

Yes
No

If not, why not? required

Present Auto Ins. Co required

Renewal Date required

Click in box to select date

Own Home? select one

Select one

Yes
No

Car #1

Year required

Make required

Model required

Type select one

Select one

2dr
4dr

Miles to work (one way) required

Annual Mileage required

Type of Anti - Theft device on vehicle required

VIN# required

Car #2

Year required

Make required

Model required

Type select one

Select one

2dr
4dr

Miles to work (one way) required

Annual Mileage required

Type of Anti - Theft Device on vehicle required

VIN# required

Car #3

Year required

Make required

Model required

Type select one

Select one

2dr
4dr

Miles to work (one way) required

Annual Mileage required

Type of Anti - Theft device on vehicle required

VIN# required

Page 3

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Liability Limit for all Cars

Bodily Injury select one

Select one

25,000 / 50,000
50,000 / 100,000
100,000 / 300,000
250,000 / 500,000

Property Damage select one

Select one

25,000
50,000
100,000
500,000

Single Limit (choose one) select one

Select one

100,000
300,000
500,000

Levels of current Uninsured Motorist coverage required

Car #1

Comprehensive Deductible select one

Select one

100
250
500
1000

Collision Deductible select one

Select one

100
250
500
1000

Tow select one

Select from list

Loss of use select one

Select from list

Car #2

Comprehensive Deductible select one

Select one

100
250
500
1000

Collision Deductible select one

Select one

100
250
500
1000

Tow select one

Select from list

Loss of use select one

Select one

Yes
No

Car #3

Comprehensive Deductible select one

Select one

100
250
500
1000

Collision Deductible select one

Select one

100
250
500
1000

Tow select one

Select from list

Loss of Use select one

Select from list

Comments required

* required

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For refund (if applicable) and privacy policies please contact Commerce Group, Inc. at www.commercegroup.net.