On-Line Automobile Insurance Quote Form

Personal Information

Name		Spouse
Driver's License Number		Driver's License Number
Address
City		State	ZIP
Home Phone		Work Phone
E-Mail Address		Current Auto Insurance Company
Renewal Date (if known)		Own Home?	Yes No
Number of People in Household		Licensed Drivers in Household
Do you have medical coverage?	Yes No
Do you have disability coverage?	Yes No

Vehicles

#	Year	Make	Model	2dr/4dr	Miles to Work (1-way)	Annual Mileage	Comprehensive Deductible	Broad Collision Deductible	Towing / Labor	Loss of Use?
1
	VIN#:
2
	VIN#:
3
	VIN#:
4
	VIN#:

Drivers

Insurance companies want to know about every licensed driver in the household.
If you have more than three, give the additional information on drivers in the comment section.

#	Driver's Name	Date of Birth	Gender	Marital Status	Moving Violations (last 3 yrs)	Accidents (last 3 yrs)
1
2
3

Liability Limit for All Cars

Choose either Bodily Injury & Property Damage or Single Limit

Bodily Injury	Property Damage	<- or ->	Single Limit
		<- or ->

Comments

Many people prefer to fax us a copy of their current policy deck sheets. Some send them as an e-mail attachment.
If you wish, please do so.
It makes our quote more accurate. Be sure to send both sides. Our 24-hour fax is 248-358-3308. We also have group discounts.
If you belong to an alumni group or you or your spouse is eligible to join one, let us know. Some other groups
(often based on employment) offer discounts.
Ask us if your group is included.

Please click on the Submit button to send your estimate request. This is not an application for insurance, and it does not obligate
this agency to issue any policy of insurance.

Our estimate will include broad collision. Basic collision can save you premium dollars.

By clicking submit and seeking a quote request I authorize and agree that up to eight insurance companies or their agents and partners may contact me using this information or to obtain additional information needed to provide quotes where permitted by law. Insurance companies or their agents that receive a quote request from this site may confirm my information through the use of a consumer report, which may include my credit score and driving record. I authorize and instruct Storm Insurance and its partners to obtain a consumer report. I acknowledge that I have read and understand and agree to be bound by them