Lake Agency

Call: 800.225.5960
810.694.2050

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Please fill out the sections below so we can contact you with your quote:

* Indicates required fields

Applicant(s) Information

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip Code:

Do you own your home or rent?

Own Rent
I am also interested in a home owner's or renter's insurance quote

All Drivers Information

Please list all licensed drivers that will drive this vehicle.

	Name	Birthdate	Sex	Marital Status	Occupation
1
2
3
4

All Drivers History

Please list all of the tickets and/or accidents for the past five years for each driver.

Driver 1:

Driver 2:

Driver 3:

Driver 4:

Your Vehicle Information

Enter either the Vehicle Identification Number (VIN) OR the Year/Make/Model of each Vehicle

	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
VIN:
Year:
Make:
Model:
Primary Driver
Distance Driven: Miles driven to work and/or school (one way)
Anti-Theft Device:
Auto Recovery Device:
Air Bags:
Anti-lock brakes:

Liability Limits for All Listed Vehicles

Do you have medical insurance?

Medical Insurance Provider:

Does it cover you in an auto accident?

Do you have disability insurance from your employer?

Choose this option:

Bodily Injury:

Property Damage:

Or this option:

Combined Single Limit:

Coverage Information

Type	Coverage Limits
Type	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Comprehensive Deductible:	None $50 $100 $250 $500	None $50 $100 $250 $500	None $50 $100 $250 $500	None $50 $100 $250 $500
Collision Deductible:	None $50 $100 $250 $500 $1000	None $50 $100 $250 $500 $1000	None $50 $100 $250 $500 $1000	None $50 $100 $250 $500 $1000
Collision Coverage Type:	Broad (If you are in an accident that is not your fault your deductible will be waived) Standard (Regardless of who is at fault, you are responsible for your deductible)
Towing:	None $50 $75 $100	None $50 $75 $100	None $50 $75 $100	None $50 $75 $100
Rental Reimbursement:	None $20 $35 $55	None $20 $35 $55	None $20 $35 $55	None $20 $35 $55

Any Additional Information

Do you have any watercraft that you want to insure?
Year	Make/Model	Length	H.P.	Top Speed	Inboard or Outboard	$ Value of Boat	$ Value of Outboard (If Applicable)
						$	$
						$	$
						$	$

Current Insurance Company:

Expiration Date:

Current Premium:

Group or Club Name:

*You may qualify for a Special Discount if you belong to a group or a club
(SAE, Credit Union, AARP, CPAs, etc.)

Do you have any affiliation with GMAC?

Additional Comments or Questions:

How would you like to be contacted with your quote?

Telephone:

E-mail:

Fax:

Postal Address:

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