Logan Ut 84321
Phone: (435) 787-1122
AUTO QUOTE
*
Name
*
e-mail
*
Telephone 1
Telephone 2
*
Address
City
ID
NV
UT
WY
*
ZIP
_______________________________________________________________________________________________
Drivers
Driver 1
Driver 2
Driver 3
Driver 4
Name
Yourself
DOB
Gender
Female
Male
Select one
Female
Male
Select one
Select one
Female
Male
Female
Male
Select one
Relationship
Insured
Spouse
Child
Other
Spouse
Child
Other
Spouse
Child
Other
Marital Status
Single
Married
Separated
Divorced
Widow
Single
Married
Separated
Divorced
Widow
Single
Married
Separated
Divorced
Widow
Single
Married
Separated
Divorced
Widow
Continuous Ins
coverage
Yes
No
Yes
No
Yes
No
Yes
No
Accidents or
tickets
Yes
No
Yes
No
Yes
No
Yes
No
_______________________________________________________________________________________________
Vehicle
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Year
Brand
Model
Sub model
Coverage
Bodily injury
25/65
50/100
100/200
100/300
250/500
300/500
500/500
500/1000
Prior Bodily
injury
Select one
25/65
50/100
100/200
100/300
250/500
300/500
500/500
500/1000
15
25
50
100
200
250
500
Property
Damage
Select one
None
Standar
Preferred
Prior Carrier
PIP
3000
5000
10000
3000 NWL
5000 NWL
10000 NWL
500/500
500/1000
Uninsured
Motorist
25/65
50/100
100/200
100/300
250/500
300/500
500/500
500/1000
No Coverage
Underinsured
motorist
10/20
20/40
25/50
25/65
50/100
100/200
100/300
250/500
300/500
500/500
500/1000
No Coverage
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
UMPD
No Coverage
3500
No Coverage
3500
No Coverage
3500
No Coverage
3500
Comprehensive
Optional
50
100
200
250
300
400
500*
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Collision
Optional
50
100
200
250
300
400
500*
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Optional
50
100
200
250
300
400
500
600
750
900
1000
2500
5000
Towing
No Coverage
25
50
75
100
Unlimited
No Coverage
25
50
75
100
Unlimited
No Coverage
25
50
75
100
Unlimited
No Coverage
25
50
75
100
Unlimited
Rental
Optional
15 / Day
20 / Day
25 / Day
30 / Day
40 / Day
50+ / Day
Optional
15 / Day
20 / Day
25 / Day
30 / Day
40 / Day
50+ / Day
Optional
15 / Day
20 / Day
25 / Day
30 / Day
40 / Day
50+ / Day
Optional
15 / Day
20 / Day
25 / Day
30 / Day
40 / Day
50+ / Day
Commute
Pleasure
Business
Farms
Artisan
Vehicle use
Commute
Pleasure
Business
Farms
Artisan
Commute
Pleasure
Business
Farms
Artisan
Commute
Pleasure
Business
Farms
Artisan
Comments
