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Personal Auto Insurance Quote Request

Please complete the following form and press "submit". Your information will automatically be forwarded to our agency. The information you provide will be kept confidential between you and our office.

Name: 
SSN:
Drivers License:
Address: 
City: 
State:   Zip:
Telephone:
Fax:
E-Mail:
Number of vehicles: Number of drivers:

Vehicle Description

Vehicle #1 (Year, Make & Model)
Vehicle #2 (Year, Make & Model) 

Vehicle Use

Vehicle #1   Miles to work or school
Vehicle #2   Miles to work or school

Driver Information

Driver #1 Name   Age   Years Licensed
Driver's Gender Male Female
Marital Status Single Married

   

Driver #2 Name   Age   Years Licensed
Driver's Gender Male Female
Marital Status Single Married

   

Driver #3 Name   Age   Years Licensed
Driver's Gender Male Female
Marital Status Single Married

   

Driver #4 Name   Age   Years Licensed
Driver's Gender Male Female
Marital Status Single Married

   

Please list all accidents (including not-at fault accidents) and violations for the last 3 years:

Homeowner or Renter Insurance

Homeowners Insurance

Coverages

Tort Option:  
Limited tort waives your right to sue for non-economic losses with four exceptions listed in the policy. We will be happy to review the exceptions or discuss your options. Please call or email if you would like to discuss your tort option in more detail.
   
Liability Limits:  
Bodily Injury and Property Damage (BI/PD)
Uninsured Motorists (UM) Stacked/Unstacked coverage: 
Underinsured Motorists (UIM) Stacked/Unstacked coverage: 
   
Basic First Party Benefits Coverage  
Accidental Death coverage:
Funeral Benefits coverage:
Work Loss Benefit Monthly/Maximum::
Medical Expenses coverage:
Extraordinary Medical Benefit Coverage:

 

Comprehensive Coverage Collision Coverage
Vehicle #1 Vehicle #1
Vehicle #2 Vehicle #2

 

Include Coverage for Towing and Labor Yes No
Include Rental Reimbursement Coverage Yes No

 

  Vehicle #1 Vehicle #2
Airbags
4 Wheel Anti-Lock Brakes Yes No Yes No
Automatic Seat Belts Yes No Yes No
Alarm System Yes No Yes No

Additional Information

Do you currently have insurance? Yes No
Do you currently own or rent a home? Own Rent
 
What is the expiration date of your current policy?		  
Which company currently provides your automobile insurance?


 

165 E. Water Street - Hughesville, PA 17737 - 570-584-3161

Offering Your Insurance Solutions

Lockard Agency Inc.