PERSONAL AUTOMOBILE APPLICATION

We at Hudson & Muma/Insure-all.Com believe that it is important to offer our customers
the most up-to-date technology available which will enhance the service they receive.

We could offer you a "quick quote" online and then give you a price and even give you a certificate - you know, like those commercials on TV?!  So why don't we?

The answer is that without ALL the proper information NO ONE can offer you instant coverage.  What do those guys on TV do?  Simple, they give you one price and then come back later on and correct the policy with the information they gather AFTER they have your deposit!  Then you get a bill for the difference!  Nice huh?  Well, we don't do that.  Getting the proper coverage at the best price takes accurate information.

It is because of this commitment that we are offering this form to aid in generating
accurate applications and forms quickly and efficiently!  
 

Remember, without complete information, we may be delayed in producing your certificate, so please complete ALL applicable fields.
* Indicates required fields.

 

 

MICHIGAN AUTOMOBILE
QUOTE REQUEST

Basic Address Information

Name:  
Address:  
City:   State: Zip:  

Home Phone:   Business Phone:
Fax: E-mail:  
Do you currently own your own home? Yes No
Are you currently insured? Yes No
Current Insurance Company:
Policy Number:
Expiration Date:

 

 

Vehicle Information
The VIN# is not required, but it will help you get a more accurate quote.

Vehicle # Year: Make: Model: Vehicle Serial #

 

Drivers Information
Driver #: Name: License#: Sex: Date of Birth:

Vehicle Use:

Vehicle # Used
for
Business?		 Pleasure Use Only? Used To and From Work? Miles One Way to Work: Used by Driver #:

Physical Damage Coverage for Vehicles:

Collision =  Damage to YOUR vehicle while it is being driven.

Comprehensive = Damage to YOUR vehicle OTHER THAN COLLISION

Type of Collision Coverage: 
            1. Broadened Collision - you will not have to pay the deductible if you are PROVEN
                                                    not at fault.

            2. Standard Collision - regardless of fault you will pay your deductible.

            3. Limited Collision - you must be LESS THAN 50% at fault or there is NO
                                                COVERAGE.  

Type of Alarm:   1. Passive (sets itself)    2. Active (you MUST set it)           

Vehicle # Collision
Deductible:		 Comprehensive
Deductible:		 Type of Collision Airbags?: Anti-Lock
Brakes?		 Alarm Type:
$
$
$
$
$
$
$
$
$
$
$
$

Vehicle # Rental Coverage: Towing & Labor:
$
$
$
$
$
$
$
$
$
$
$
$



Tickets & Accidents:

Dates of Accidents Dates of Tickets
in last in last
Driver #: 3 years: 3 years: Describe Ticket or Accident

This information is not required but will help in getting a more accurate quote

Do you have medical insurance?  (if so it can reduce the cost of No-Fault Coverage):

Do you have medical inusrance:
 Yes No
Current Insurance Company:
Policy Number:
Expiration Date:

Do you have disability insurance?  (if so it can reduce the cost of No-Fault Coverage):

Do you have disability inusrance:
 Yes No
Current Insurance Company:
Policy Number:
Expiration Date:

Desired Coverages:

LIABILITY COVERAGE:

Split Limit of
Liability:		 Limit of
Property Damage:		 Combined Limit of
Liability:
$ $ $


UNINSURED MOTORIST COVERAGE:

Split Limit of
Liability:		 Limit of
Property Damage:		 Combined Limit of
Liability:
$ $ $

UNDERINSURED MOTORIST COVERAGE:

Split Limit of
Liability:		 Limit of
Property Damage:		 Combined Limit of
Liability:
$ $ $



Your request for a quote or the form

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