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Fill out the form below to request a free
auto insurance quote. We'll review coverage
options from dozens of top carriers and send
you the best quote. Any questions, just contact
Summit Insurance Agency at 1-330-655-0655.

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AUTO OR MOTORCYCLE INSURANCE QUOTE REQUEST:
Fill out the form below to obtain a free, no-obligation quote for your car or other personal vehicle, and we will contact you. If you prefer to give information over the phone, fill out the required contact information below and we will give you a call.
  
CONTACT INFORMATION:
*Required Fields
*Contact Name:
E-mail: (requested)
*Address:
*City:    *State:    *Zip Code:  
*Area Code:    *Phone:      Area Code:    FAX:  
  
Please indicate how you would prefer us to contact you if we need any additional information.
  Phone
  Email
  Fax
  Mail
  
Primary Insured's Driver's Licence #  
Have you had continuous coverage for at least 12 months?     Yes   No
If not, why not?
Present Auto Insurance Company  
Renewal Date  
Do you own a home?     Yes   No
 
 Car #1
Year       Make       Model  
2dr/4dr       Miles to work (one way)       Annual Mileage  
Type of Anti-theft Device on Vehicle  
Vin#  
  
 Car #2
Year       Make       Model  
2dr/4dr       Miles to work (one way)       Annual Mileage  
Type of Anti-theft Device on Vehicle  
Vin#  
 
 Car #3
Year       Make       Model  
2dr/4dr       Miles to work (one way)       Annual Mileage  
Type of Anti-theft Device on Vehicle  
Vin#  
  
 Driver #1 Information
Driver Name
Occupation
Business
Highest Level of Education
Date of Birth (MM/DD/YYYY)  
Gender  Male   Female
Marital Status  
Moving violations in last 3 years  0   1   2   3
Please provide the date and a brief description of each violation.
Accidents in last 3 years  0   1   2   3
Please provide the date and a brief description of each accident.
 
 Driver #2 Information
Driver Name
Occupation
Business
Highest Level of Education
Date of Birth (MM/DD/YYYY)  
Gender  Male   Female
Marital Status  
Moving violations in last 3 years  0   1   2   3
Please provide the date and a brief description of each violation.
Accidents in last 3 years  0   1   2   3
Please provide the date and a brief description of each accident.
 
 Driver #3 Information
Driver Name
Occupation
Business
Highest Level of Education
Date of Birth (MM/DD/YYYY)  
Gender  Male   Female
Marital Status  
Moving violations in last 3 years  0   1   2   3
Please provide the date and a brief description of each violation.
Accidents in last 3 years  0   1   2   3
Please provide the date and a brief description of each accident.
 
 Liability Limit for All Cars
Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury Property Damage Single Limit   (choose one)
25,000/50,000 25,000 60,000
50,000/100,000 50,000 100,000
100,000/300,000 100,000 300,000
250,000/500,000 500,000 500,000
Levels of current Uninsured Motorist coverage  
 
 Car#1
Deductible Comprehensive  100    250     500
Deductible Collision  250    500     1000
Tow  Yes
Loss of Use  Yes
 
 Car#2
Deductible Comprehensive  100    250     500
Deductible Collision  250    500     1000
Tow  Yes
Loss of Use  Yes
 
 Car#3
Deductible Comprehensive  100    250     500
Deductible Collision  250    500     1000
Tow  Yes
Loss of Use  Yes
 
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