Auto Insurance Quote
To provide an accurate quote, we will ask you a series of questions and will confirm some of this information through consumer reports, which may include credit information. We will provide you the source of these consumer reports if you are interested. This information will be available to quickquoteinsurance.com and future reports may be used for an update, renewal or extension of the insurance. Do you wish to continue?
First Name
Last Name
Home Phone Number
Work Phone Number
Mobile Phone Number
E-mail
Current Insurance Company
How many months of continuous coverage
Social Security#
Some insurance carriers require the use of consumer reports to rate insurance policies, therefore social security numbers are rquired to obtain quotes from these companies.
Address
City
State
Zip
Drivers License #
Date Licensed
Expiration Date of current Policy
Gender Male Female
Date Of Birth
Number of consecutive years licensed
License State
Married: Yes No
Does Driver 1 have any driving certificates?:
Date Driver Completed Course?
Is driver 1 a student at school 100 miles or more from home without a car? YesNo
Does driver 1 have limited driving privilege due to physical handicap? YesNo
Please tell us about the driving history for the past five years, for all drivers. To include accidents /violations /comprehensive claims, set the number for each type and person. Or to update an existing incident loss, click on the specific incident.
Accident(s) Violation(s) Comp Loss(es)
We require the past 5 years of accidents, violations and comprehensive losses.

Vehicles to Insure
If you do not have incidents please indicate the number of vehicles you would like to insure and click Continue, otherwise list your Accident(s), Violation(s), and Comp Loss(es) and click Continue.
Vehicles to insure: Vehicle(s)

Vehicle Number 1: Year
Make
Model
Vehicle Number 2: Year
Make
Model
Vehicle Number 3: Year
Make
Model
Please make the appropriate selection for this vehicle.
Anti-Theft Device
Annual Miles
Garage Zip
# of days per week this vehicle is driven to work, school or train/bus station.
# of miles driven one-way to work, school or train/bus station.
Please indicate how the vehicle is used.
Bodily Injury Coverage
Property Damage Coverage
Medical Payment Coverage
1Uninsured Motorist Coverage
Personal Injury Protection (No Fault)
OBEL
Deductibles
Coordination of Benefits
On your current auto insurance, what is your Bodily Injury limit
Comprehensive Coverage
Collision Coverage
Extended Transportation Expense Coverage
Towing Coverage
Collision Coverage, Transportation Expense Coverage and Towing Coverage are available only when Comprehensive Coverage is selected
Full Glass Coverage - no deductible applies to glass loss (must have comprehensive coverage), check here
     
    1You automatically receive $25,000/$50,000 (per person/per accident) of uninsured motorist coverage. Please note, "uninsured motorist coverage" ONLY covers incidents that occur inside the state of New York, while "supplementary uninsured/underinsured coverage" covers incidents in any state or Canadian Province.

Receiving a price quotation does not obligate you to purchase a policy.