Michigan Personal Auto Insurance Quote

Untitled Document

This form is for the use of customers of Hudson & Muma
and insure-all.com only.

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, 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 at an accurate rate.

So you ask, "What do those guys on TV do?"

Simple, they give you one price when you first contact then 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? Get the customer roped THEN give them the REAL price.

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!

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE. * Indicates required fields

....

Basic Address Information
Name:
Address:
City:	State:	Zip:

Home Phone:		Work Phone:
Fax:		Cell Phone:

Client Email Address:

Previous Address
(if moved within the last 60 days or if home is
a new purchase)

Prev. Address:
City:		State:		Zip:

Do you currently own your own home?	Yes No
Are you currently insured?	Yes No
Current Insurance Company:
Policy Number:
Expiration Date:

Vehicle #	Year:	Make:	Model:	Vehicle Serial #

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

TYPES 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.

1. Passive (sets itself)

2. Active (you MUST set it)

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

Other Options:

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

Tickets & Accidents:

	Dates of Accidents	Dates of Tickets
	in last	in last
Driver #:	5 years:	5 years:	Describe Ticket or Accident

Medical & Disability Coverage:

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:
$	$	$

Confirmation Email Address:

(Confirmation Email - We need this to send you a confirmation
receipt for this form. See our Privacy Policy HERE)

insure-all.com

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Auto Insurance Quote Request
(Michigan)

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Auto Insurance Quote Request (Michigan)

Auto Insurance Quote Request
(Michigan)