Sears & Associates, Inc.

Request an Auto Insurance Quote Online:

Please fill out the form below, and we will be in touch with you as soon as possible. Coverage is not bound until you have been contacted by an agent. The more information you provide us, the more accurate the quote will be. Fields marked with * are required.

Note: This information is not being transmitted over a secure server. Feel free to contact our agency if you have any questions.

Full Name:
Home Address:
Home Phone:
* E-mail Address:
Date of Birth:
Employer's Name:
How many years with this employer?
Previous Employer (if with current employer less than two years):
Highest Level of Education:
Spouse's Full Name:
Spouse's E-mail Address:
Spouse's Date of Birth:
Spouse's Employer:
How many years with spouse's employer?
Spouse's Previous Employer (if with current employer less than two years):
Spouse's Highest Level of Education:
How many years at this address?
Previous Address (if at current for less than two years):
Type of Residence (if 'Other' please specify in 'Notes' section):
Own or Rent?
Driver Information:
Driver's License #:
State:
Year First License Issued:
Spouse's License #:
State:
Year Spouse's First License Issued:
Name of Other Driver:
Sex:
Date of Birth:
Driver's License #:
State:
Year First License Issued:
Any revoked/suspended licenses in the last five years?
If so, list and explain:
Any driver previously cancelled?
If so, list and explain:
Vehicle Information:
Vehicle #1
Make:
Model:
Year:
Vehicle Identification Number (VIN):
Anti-Theft?
Anti-Lock Brakes?
Annual Miles:
Current Odometer Reading:
Purpose?
Miles One-Way (if for work/school):
Garaged?
Vehicle #2
Make:
Model:
Year:
Vehicle Identification Number (VIN):
Anti-Theft?
Anti-Lock Brakes?
Annual Miles:
Current Odometer Reading:
Purpose?
Miles One-Way (if for work/school):
Garaged?
Vehicle #3
Make:
Model:
Year:
Vehicle Identification Number (VIN):
Anti-Theft?
Anti-Lock Brakes?
Annual Miles:
Current Odometer Reading:
Purpose?
Miles One-Way (if for work/school):
Garaged?
Vehicle #4
Make:
Model:
Year:
Vehicle Identification Number (VIN):
Anti-Theft?
Anti-Lock Brakes?
Annual Miles:
Current Odometer Reading:
Purpose?
Miles One-Way (if for work/school):
Garaged?
Accidents/Violations:
Accident/Violation #1
Date and Time:
Fault:
Vehicle:
Bodily Injury/Death:
Amount Paid Out:
Accident/Violation #2
Date and Time:
Fault:
Vehicle:
Bodily Injury/Death:
Amount Paid Out:
Accident/Violation #3
Date and Time:
Fault:
Vehicle:
Bodily Injury/Death:
Amount Paid Out:
Notes/Special Instructions:

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