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Auto/Vehicle Quote

Please complete the following Auto/Vehicle Quote form and click Submit. A Wickersham Insurance Agent will contact you with your quote information once we have processed your request.

Contact Information
First Name *
 Last Name *
Street Address
City
 State
 		Zip Code
E-mail Address
Contact Phone *
 Best Time to Call
AM    PM   
 

Vehicle Information

 Vehicle #1 - Please indicate the type of vehicle being quoted on in this section:

Type of Vehicle
Regular Auto    Commercial Auto    Motorcycle    RV   
Travel Trailer    Boat    Other   
Year
 Make
 Model
 Body Type
Vehicle ID# (VIN)
 Annual Mileage
 Drive to School/Work?
 		# Miles Each Way
Engine cc's (for motorcycles only)

 If vehicle is an RV or Travel Trailer, please complete these items:

Cost New
 Current Value
 Length
 Years Experience w/Vehicle

 If vehicle is kept at an address other than that listed above, please indicate below:

City
 State
 		Zip Code

 Vehicle #2 - Please indicate the type of vehicle being quoted on in this section:

Type of Vehicle
Regular Auto    Commercial Auto    Motorcycle    RV   
Travel Trailer    Boat    Other   
Year
 Make
 Model
 Body Type
Vehicle ID# (VIN)
 Annual Mileage
 Drive to School/Work?
 		# Miles Each Way
Engine cc's (for motorcycles only)

 If vehicle is an RV or Travel Trailer, please complete these items:

Cost New
 Current Value
 Length
 Years Experience w/Vehicle

 If vehicle is kept at an address other than that listed above, please indicate below:

City
 State
 		Zip Code

 Vehicle #3 - Please indicate the type of vehicle being quoted on in this section:

Type of Vehicle
Regular Auto    Commercial Auto    Motorcycle    RV   
Travel Trailer    Boat    Other   
Year
 Make
 Model
 Body Type
Vehicle ID# (VIN)
 Annual Mileage
 Drive to School/Work?
 		# Miles Each Way
Engine cc's (for motorcycles only)

 If vehicle is an RV or Travel Trailer, please complete these items:

Cost New
 Current Value
 Length
 Years Experience w/Vehicle

 If vehicle is kept at an address other than that listed above, please indicate below:

City
 State
 		Zip Code

 Vehicle #4 - Please indicate the type of vehicle being quoted on in this section:

Type of Vehicle
Regular Auto    Commercial Auto    Motorcycle    RV   
Travel Trailer    Boat    Other   
Year
 Make
 Model
 Body Type
Vehicle ID# (VIN)
 Annual Mileage
 Drive to School/Work?
 		# Miles Each Way
Engine cc's (for motorcycles only)

 If vehicle is an RV or Travel Trailer, please complete these items:

Cost New
 Current Value
 Length
 Years Experience w/Vehicle

 If vehicle is kept at an address other than that listed above, please indicate below:

City
 State
 		Zip Code

 Liability Limit (for ALL vehicles)
 Select limit for Bodily Injury and Property Damage or for Single Limit, alone.

Bodily Injury Limit
 		Property Damage Limit
 		       Single Limit

 Other Limits (for ALL vehicles)

Medical Payments
 		Uninsured/Under-Insured Motorist

 Deductibles and Miscellaneous

Vehicle #1
Comprehensive Deductible
 		Collision Deductible
Towing?
Yes   
Full Glass?
Yes   
Rental Reimbursement?
Yes   
Vehicle #2
Comprehensive Deductible
 		Collision Deductible
Towing?
Yes   
Full Glass?
Yes   
Rental Reimbursement?
Yes   
Vehicle #3
Comprehensive Deductible
 		Collision Deductible
Towing?
Yes   
Full Glass?
Yes   
Rental Reimbursement?
Yes   
Vehicle #4
Comprehensive Deductible
 		Collision Deductible
Towing?
Yes   
Full Glass?
Yes   
Rental Reimbursement?
Yes   
 

Driver Information

 Driver #1

Driver's Name
 Relation
 Date of Birth
Sex
 		Marital Status
 		Driver's License #
 State
 		Years Licensed
Check Courses You've Completed in Last 3 Years:
Driver's Ed    Accident Prevention   

 Driver #2

Driver's Name
 Relation
 Date of Birth
Sex
 		Marital Status
 		Driver's License #
 State
 		Years Licensed
Check Courses You've Completed in Last 3 Years:
Driver's Ed    Accident Prevention   

 Driver #3

Driver's Name
 Relation
 Date of Birth
Sex
 		Marital Status
 		Driver's License #
 State
 		Years Licensed
Check Courses You've Completed in Last 3 Years:
Driver's Ed    Accident Prevention   

 Driver #4

Driver's Name
 Relation
 Date of Birth
Sex
 		Marital Status
 		Driver's License #
 State
 		Years Licensed
Check Courses You've Completed in Last 3 Years:
Driver's Ed    Accident Prevention   
 

Comments / Questions

Please include any comments or questions you feel appropriate for this quote. If you have additional information that could not be included above (additional drivers or vehicles, etc.), please feel free to enter that here.

* Required to submit this form



Click here to see current results.


Wickersham Insurance Agencies

758-7999

788-1800

2160 Hwy. 95 Suite #2
Bullhead City, AZ 86442

8550 Hwy. 95
Mohave Valley, AZ 86440

Colorado River Insurance Center

855-2742

2005 McCulloch Blvd.
Lake Havasu City, AZ 86403

EMAIL: wickersham@frontiernet.net








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