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You can also contact us at:


Corner E. Laurel Circle
Mt. Pleasant Road
P.O. Box 129
Norvelt, Pa 15674

Phone: (724) 423-6775
Fax: (724) 423-6758


Auto Quote

Please complete the following so we may prepare a free, no obligation auto insurance quote for you:
Contact Information
Name:
Address:
City: *State: Zip Code:
Day Phone: Fax:
Evening Phone: E-Mail:
* Quotes only available to PA residents
Current Policy Information
(If you are not currently insured, please skip to Vehicle Information)

Current Auto Insurance Company:
Policy Effective Dates: From: To:
Bodily Injury Liability Limit:
Property Damage Liability Limit:
Tort Option: Full: Limited: Unknown:
Uninsured Motorists Limit:
Stacked: Non - Stacked: Unknown:

Under-Insured Motorists Limit:
Stacked: Non-Stacked: Unknown:

Medical Expense Benefit:
Income Loss Benefit:
Funeral Expense Benefit:
Accidental Death Benefit:
Extra-Ordinary Medical Benefit:

Vehicle Information

Vehicle 1
Year:
Make:
Model:
VIN:
Air Bags:
Anti-Lock Brakes:
Anti-Theft Device:
Comprehensive Deductible:
Collision Deductible:
Towing and Labor:
Rental Reimbursement:
Usage:


Vehicle 2
Year:
Make:
Model:
VIN:
Air Bags:
Anti-Lock Brakes:
Anti-Theft Device:
Comprehensive Deductible:
Collision Deductible:
Towing and Labor:
Rental Reimbursement:
Usage:


Vehicle 3
Year:
Make:
Model:
VIN:
Air Bags:
Anti-Lock Brakes:
Anti-Theft Device:
Comprehensive Deductible:
Collision Deductible:
Towing and Labor:
Rental Reimbursement:
Usage:


Vehicle 4
Year:
Make:
Model:
VIN:
Air Bags:
Anti-Lock Brakes:
Anti-Theft Device:
Comprehensive Deductible:
Collision Deductible:
Towing and Labor:
Rental Reimbursement:
Usage:

Driver Information
Driver 1
Name:
Sex: Male: Female:
Birth Date:
Marital Status:
Driver Training:
Good Student:
55 Alive:


Driver 2
Name:
Sex: Male: Female:
Birth Date:
Marital Status:
Driver Training:
Good Student:
55 Alive:


Driver 3
Name:
Sex: Male: Female:
Birth Date:
Marital Status:
Driver Training:
Good Student:
55 Alive:


Driver 4
Name:
Sex: Male: Female:
Birth Date:
Marital Status:
Driver Training:
Good Student:
55 Alive:
Please list any Accidents or Violations for any driver within the last 5 years:


Comments or Special Considerations:


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