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Auto Insurance Quote Request Form

Fill out the form below to obtain your auto insurance quote. The quotes provided here are for Connecticut only. To obtain an accurate quote, please be as complete as possible. This form can handle up to 4 drivers and 2 vehicles. For additional drivers or vehicles, please call us.

Client Information

Name:

Business Name:

Address1:

Address2:

City/State/Zip: / /

Phone:

Fax:

Email:

Driver Information
	Driver 1	Driver 2	Driver 3	Driver 4
Name (as it appears on drivers license)
State Licensed
Drivers License Number
Years Driving Experience
Date of Birth
Social Security Number
Please check each question that applies to driver.
Completed a Defensive Driving Course?
	Driver 1	Driver 2	Driver 3	Driver 4
Defensive Driving
Completed Drivers Ed Course (applies to males less that 21 years old)?
	Driver 1	Driver 2	Driver 3	Driver 4
Drivers Ed
Are there any claims, tickets, accidents (regardless of fault), suspensions or revocations in last 5 years? If checked provide details in comments field at the end of this form.
	Driver 1	Driver 1	Driver 1	Driver 1
Claims etc

Vechicle Information
	Vehicle 1	Vehicle 2
Year
Make
Model
City Primarily Garaged
Please check all that apply to the vehicle.
Airbags
Automatic Seatbelts
Daytime Running Lights
Antilock Braking System (ABS)
Antitheft device (Alarm)
Vehicle Recovery System (LoJack)

Type of Insurance Coverage Required If you are unsure about the types of coverage or the amount of coverage your situation might call for, leave the default values and we can discuss when we contact you with your quote.
	Vehicle 1	Vehicle 2
Bodily Injury to Others
Damage to someone else's property:
Liability CSL :
Bodily Injury caused by Uninsured Motorist:
Comprehensive Deductible:
Collision Deductible:
Medical Payments:
Full Glass Coverage:
Towing and Labor:
Substitute Transportation:

Select the Method you would like this Quote Forwarded to you If the address or number you want the quote sent to is different from what you specified above then specify the new one after the selected method. We will send you a prompt reply. Thank you for considering the Prindle Insurance Agency.
Email
Fax
Letter


		/ /
Would you like a rep to call you?

Thank you for considering the Prindle Insurance Agency! Be sure you have completed the required fields and have provided us a method of forwarding your Auto Insurance Quote to you. If you have any other information you would like for us to consider or you have general questions or comments, please enter them in the box below, then click the submit button. We will respond to you promptly.

Comments / Questions


Thank you for considering the Prindle Insurance Agency!

The Prindle Insurance Agency is a member in good standing with:

The National Association of Independent Insurance Agents

The National Association of Professional Insurance Agents.

Prindle Insurance Agency
22 West Main Street
Sharon CT 06069
Phone: 1 860 364 5000
Toll Free Number: 1 877 422 4555
Fax: 1 860 364 5072

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