Auto Insurance Quote Form

-About The Agency
-A Professional Agency

with Personal Service

-Who We Are

      -Homeowners
      -Automobile
      -Umbrella Liability
      -Boats / Yachts
      -Motorcycles

      -Homeowners FAQ's
      -Auto FAQ's
      -Business FAQ's
      -Financial FAQ's

    127 Norwich Road
    P.O. Box 405
    Central Village, CT 06332

    Phone: (860) 564-3315
    1-800-292-1127
    Fax: (860) 564-8253

Please, residents of CT only.

Name:

E-mail:

Website

Phone Numbers:

  Daytime:

  Evening:

  Fax:

How would you prefer to be contacted regarding your quote? Phone Fax Mail E-mail

If you would prefer to be contacted by phone, please let us know the best time to call.

Address:

City:

State: Zip:

Do you currently own your home or rent? Own Rent

What is the Expiration Date of your current insurance?

Driver Information

Driver #1
Name:
Relationship to applicant:
Sex:
Marital Status:
D.O.B
Which vehicle does he/she drive?
Driver #2
Name:
Relationship to applicant:
Sex:
Marital Status:
D.O.B
Which vehicle does he/she drive?
Driver #3
Name:
Relationship to applicant:
Sex:
Marital Status:
D.O.B
Which vehicle does he/she drive?
Driver #4
Name:
Relationship to applicant:
Sex:
Marital Status:
D.O.B
Which vehicle does he/she drive?

Driver History

Currently insured with (company name, not agency)?
6 months 12 months
Current Premium:

Have you or any other driver in your household:

Had a ticket in the last 3 years?
Yes No

Had a license suspended or revoked in the last 6 years?
Yes No

Had a financial responsibility filing in the last 6 years?
Yes No

Made any claims in the last 5 years?
Yes No

If you answered yes to any of the above questions, please explain:

Vehicle #1 Information:

Year:
Make:
Model:
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Work School
Vehicle ID# (VIN):
If driven to school or work, how many days per week?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

Vehicle #2 Information:

Year:
Make:
Model:
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Work School
Vehicle ID# (VIN):
If driven to school or work, how many days per week?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

Vehicle #3 Information:

Year:
Make:
Model:
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Work School
Vehicle ID# (VIN):
If driven to school or work, how many days per week?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

Vehicle #4 Information:

Year:
Make:
Model:
Primary driver:
Annual mileage:
Is the vehicle driven to school or work?	Work School
Vehicle ID# (VIN):
If driven to school or work, how many days per week?
If driven to school or work, how many miles one way?
Is the vehicle in any way modified or customized?	Yes No
Is there any existing damage to the vehicle?	Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address:
City:
State:
Zip:

Coverage Options:

Bodily injury liability:
Property damage liability:
Uninsured / Underinsured Motorist Limit:
Medical-personal injury protection:

Coverage Deductibles

	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Comprehensive deductible:
Collision deductible:
Rental Reimbursement:

Questions, Comments or Additional Automobile Information:

Please note:
Quintal Agency only services residents and businesses in the state of CT.