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Quote Form
Please answer each question that applies to you fully and click "submit" to send to an agent at B.R.Knuckles Insurance. We appreciate the opportunity to service your insurance needs.
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Email Address
Your answer
Name:
Your answer
Phone Number
Your answer
How do you prefer to be contacted?
Phone
Email
Text
Are there any other drivers in your household?
Yes
No
Other:
Clear selection
If you answered "yes" to the previous question, list Name/DOB/Driver's License Number of said driver(s).
Your answer
Date of Birth
MM
/
DD
/
YYYY
What is your driver's license number?
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What is your occupation?
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What is your mailing address?
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What is your street address?
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How long have you lived there?
Your answer
If you have lived there less than 2 years, what was your prior address?
Your answer
Do you own your home or rent it? Rent
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Have any household drivers been involved in at-fault accidents or been convicted of moving violations in the last 3 years?
Yes
No
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If you answered "yes" to the previous question, please explain here.
Your answer
What company currently provides your auto insurance?
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What coverage are you interested in?
Liability
Comprehensive
Full Coverage
Would you like rental car and roadside assistance coverage?
Yes
No
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Some of our companies offer a "paperless" discount. Is this something you would be interested in?
Yes
No
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How would you like to pay your premium?
Monthly
Quarterly
Every 6 months
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Would you be interested in paying by EFT if there is a discount involved?
Yes
No
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Do you drive uber, lyft, etc?
If yes, please specify which vehicle you drive uber/lyft/etc with.
Yes
No
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Vehicle 1
Please list the year, make, model, and VIN for the vehicle and how long you have owned it. Also, state whether you would like full coverage, liability + comprehensive, or liability only coverage for the vehicle.
Your answer
Vehicle 2
Please list the year, make, model, and VIN for the vehicle and how long you have owned it. Also, state whether you would like full coverage, liability + comprehensive, or liability only coverage for the vehicle.
Your answer
Vehicle 3
Please list the year, make, model, and VIN for the vehicle and how long you have owned it. Also, state whether you would like full coverage, liability + comprehensive, or liability only coverage for the vehicle.
Your answer
Vehicle 4
Please list the year, make, model, and VIN for the vehicle and how long you have owned it. Also, state whether you would like full coverage, liability + comprehensive, or liability only coverage for the vehicle.
Your answer
How did you hear about us?
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