Insurance and Financial Services

Motor Vehicle Insurance Write your auto & homeowners with us and receive additional discounts! Motor Vehicle Quote Form Please use this form to request a quote. We will respond by the next business day. *Denotes required field. Thank you! Insured Your Full Name: * EMail Address: * Street Address:  City, State, Zip Code:   City:       State: AB AK AL AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NV NY OH OK ON OR PA PQ PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY       Zip: Fax:  Home Phone: ...and best time to call? Business Phone: Your birth date: (mm/dd/yy): Your Driver's license info: Lic #: State: Exp: Please list all operators: Driver #2 Name:     DOB:   Lic #: State: Exp: Driver #3 Name:     DOB:   Lic #: State: Exp: Driver #4 Name:     DOB:   Lic #: State: Exp: Car #1   Year:Make: Model: Does car have AAA? Yes     No Anti Theft Device? Yes     No Vehicle Air Bag? Yes     No Approximate annual mileage:   Discount under 7,000 miles per year. Collision: Deductible?: $500 $300 $1000 $2000 Comprehensive: Deductible?: $500 $300 $1000 $2000  Automatically includes no deductible on glass. Uninsured Motorist: Per Person/Per Accident: $100,000/$300,000 $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 Optional Bodily injury to others: Per Person/Per Accident: $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 Property Damage: $100,000 $200,000 $250,000 Medical Payments: $5,000 $10,000 $20,000 $25,000 Rental Coverage: $15 per day/$450 max $30 per day/$900 max $45 per day/1350 max $100 per day/$3000 max Underinsured Motorist: Per Person/Per Accident: $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 Car #2   Year:Make: Model: Does car have AAA? Yes     No Anti Theft Device? Yes     No Vehicle Air Bag? Yes     No Approximate annual mileage:   Discount under 7,000 miles per year. Collision: Deductible?: $500 $300 $1000 $2000 Comprehensive: Deductible?: $500 $300 $1000 $2000  Automatically includes no deductible on glass. Uninsured Motorist: Per Person/Per Accident: $100,000/$300,000 $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 Optional Bodily injury to others: Per Person/Per Accident: $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 Property Damage: $100,000 $200,000 $250,000 Medical Payments: $5,000 $10,000 $20,000 $25,000 Rental Coverage: $15 per day/$450 max $30 per day/$900 max $45 per day/1350 max $100 per day/$3000 max Underinsured Motorist: Per Person/Per Accident: $20,000/$40,000 $40,000/$60,000 $50,000/100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $1,000,000/$1,000,000 How would you like your quote delivered? U.S mail E-mail Call Me! Fax Please provide any additional information or special requirements: How did you hear about us? Television Ad Mailing Yellow Pages Internet A Current Client Press when finished Home | Contact Info | Business | Financial Personal | Claim Forms | Quote Forms | Related Sites Copyright © 2002 Zemaitis-Baker Insurance All rights reserved. This website is developed and maintained by Internet Resources. Send problems or comments to the Webmaster. This page was last updated March 11, 2008