Landfried-Fanta Insurance Agency

Auto Quote

Insured Information
Insured Name *
Address *
City *
State/Province *
Zip/Postal Code *
Phone *
Email
Once your basic contact info has been entered you may submit this form at anytime for an agent to contact you. How would you like to be contacted? Email
Phone
If by phone, list when is good for you:
Current Insurance
Do you presently have Auto Insurance? * Yes  No
Company Name
Renewal Date
Have you been cancelled or non-renewed in the past 3 years? Yes  No
Coverages
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Rental Reimbursement Yes  No
Roadside Assistance Yes  No
Licensed Drivers
1. (Primary Driver)
License Number *
License State
Gender * Male  Female
Marital Status * Married
Single
Divorced
Widowed
Date of Birth *
Occupation
Good Student Yes  No
Driver Training Yes  No
Tickets and Accidents
(last 5 years)
Name on License
License Number
License State
Gender Male  Female
Marital Status Married
Single
Divorced
Widowed
Date of Birth
Relation to Applicant
Occupation
Good Student Yes  No
Driver Training Yes  No
Tickets and Accidents
(last 5 years)
Other Drivers
Please provide the names, birthdates, and drivers license numbers of any other residents in your household licensed to drive.
  Name
1.
2.
3.
4.
Vehicle(s) Information
1.
Year *
Make *
Model *
VIN
Annual Mileage
# of Doors
4-Wheel Drive Yes  No
Alarm System Yes  No
Air Bags Yes  No
Anti-Lock Brakes Yes  No
Year
Make
Model
VIN
Annual Mileage
# of Doors
4-Wheel Drive Yes  No
Alarm System Yes  No
Air Bags Yes  No
Anti-Lock Brakes Yes  No
Additional Information
Addition Information
Please list any other vehicles or information
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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