Personal Auto Quote Request

How did you hear about SSM:
Effective Date:
Your Name:
Your Mailing Address: Street
City                                 State                                 Zip
     
Your Preference: Please call me with quote
Please send quote via e-mail.
E-mail Address:
Daytime Phone #:
Cell Phone #:
Evening Phone #:
Best Time to Call:
Current coverage: Company:                         Expiration Date:
  
Bankruptcy in the past 5 years: Yes
No
Do you own any ATV's (list):
Liability Limits and Coverage:
Please select the coverage and limits that apply to your vehicles.
Bodily Injury
 		Property Damage
 		Medical Payments
Uninsured Motorists/Underinsured Motorists

Uninsured Motorists Property Damage
 		Enter limits here if you don't see them listed.
Is it okay if we run your insurance score? Yes    No
Your Vehicles:   If you have more than four vehicles, please list them in the comments box or call our office.

 
Vehicle 1.
Year          Make and model:
  
VIN (Vehicle Identification Number):
Passive Restraint:

Theft Alarm: Yes    No

Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverage: Check all that apply.
Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Full Glass Coverage
Vehicle 2.
Year          Make and model:
  
VIN (Vehicle Identification Number):
Passive Restraint:

Theft Alarm: Yes    No

Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverage: Check all that apply.
Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Full Glass Coverage
Vehicle 3.
Year          Make and model:
  
VIN (Vehicle Identification Number):
Passive Restraint:

Theft Alarm: Yes    No

Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverage: Check all that apply.
Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Full Glass Coverage
Vehicle 4.
Year          Make and model:
  
VIN (Vehicle Identification Number):
Passive Restraint:

Theft Alarm: Yes    No

Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverage: Check all that apply.
Towing and Labor
 Rental Reimbursement
 Loan Lease Gap
Full Glass Coverage
Driver Information:   If there are more than four drivers, please list them in the comments box or call our office.
Driver 1:
 Name:
DOB:           Sex:        Marital Status:
         
Driver 1 Occupation:
Social Security #:   -or-   Drivers' License No:
   
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 avg. or better)
 At School over 100 miles away.
 
 Driver 2:
 Name:
DOB:           Sex:        Marital Status:
         
Driver 2 Occupation:
Social Security #:   -or-   Drivers' License No:
   
Has Driver 2 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 avg. or better)
 At School over 100 miles away.
 
Driver 3:
 Name:
DOB:           Sex:        Marital Status:
         
Driver 3 Occupation:
Social Security #:   -or-   Drivers' License No:
   
Has Driver 3 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 avg. or better)
 At School over 100 miles away.
 
 		 Driver 4:
 Name:
DOB:           Sex:        Marital Status:
         
Driver 4 Occupation:
Social Security #:   -or-   Drivers' License No:
   
Has Driver 4 had any accidents or violations
in the past 3 years?  If yes, please explain below:
Good Student Discount (3.0 avg. or better)
 At School over 100 miles away.
 
 
Employer Name approved for Group Discount:
Are there coverages missing on your current policy:

What are you unhappy with on your current policy:

What other policies do you have and when do you review them?

 Please use the box below to enter any additional information:

Do you make your insurance decisions alone or with another person?  Alone    With Another Person

When is the best time for you to come to our office and discuss your coverage with one of our agents?

We cannot bind coverage from an email or voicemail request.  Coverage is bound after you receive a written email or telephone call from our agency staff confirming coverage is in force.

Thank you for allowing us to review your coverage!  If you have not heard from us within one business day please contact us again.

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  Stahl Stoller Meyer Insurance Center: Paulding Location: 419-399-3777 • Van Wert Location: 419-232-4776

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