Sam Heron Lapeer Michigan Insurance Life Home Auto

Auto Insurance Quote request

Your Name:
Phone:
Fax:
E-mail:
Address:
City:
State:
Zip:
Do you belong to any groups? (Ex. AARP, Credit Union, Sam's Club)
Your Birth Date:
Any Tickets or Accidents in the last 2 years or any major violations in the last 5 years? Please Explain.

Marital Status:
Any other licensed drivers in your household?			Yes No
Other Insured's Name		Relationship	Birth date

Any Tickets or Accidents in the last 2 years or any major violations in the last 5 years? Please Explain.
Other Insured's Name		Relationship	Birth date

Any Tickets or Accidents in the last 2 years or any major violations in the last 5 years? Please Explain.
Other Insured's Name		Relationship	Birth date

Any Tickets or Accidents in the last 2 years or any major violations in the last 5 years? Please Explain.
Have you had coverage in force for 6 continuous months?			Yes No
Do you have medical insurance? Yes No			With who?
Vehicles:
Year	Make	Model	Vehicle ID Number



Limit of Liability:		Bodily Injury / Property Damage:
Uninsured / Underinsured Motorist		Bodily Injury / Property Damage:
Towing & Labor:			$25 $50 $75
Rental Reimbursement:			Yes No
Vehicle usage
Work miles
Comprehensive Option			Deductible: $100 $250 $500
Collision Option Limited Broad Standard			Deductible $250 $500 $1000

Additional Comments:
Please check out our Life and Home Rates: Would also like to submit quote request for Life Insurance Would also like to submit quote request for Home Owners Get home and auto insurance and receive a 15% discount on each!