Advantis Insurance Services

 If you could choose from over 500 insurance companies - Why wouldn’t you?

Licensed in California only

Click here for a fax version.

 Auto Insurance Quote Request

We have tried to keep the following form as brief as possible, but please provide as much information as possible in the additional information field at the bottom for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

 Personal Information

Name: First

 

 Last

 

Street Address

 

City/State/Zip

 City State Zip

Contact Info

 Phone E-mail (required)

Contact  Preference

 How would you like for us to contact you?
 If by phone, what would be the best time for us to call?

 Current Insurance Information

 I have been continuously insured without interruption for years and months.

 Vehicle Information - Vehicle #1

  Year

  Make (e.g. Chevrolet)

  Model (e.g. Lumina)

  Estimated annual mileage   Miles driven to work daily (each way)

  Please select any of the following that are applicable:  Alarm
  Garage Locked Private    Carport

 Vehicle Information - Vehicle #2

  Year

  Make (eg Chevrolet)

  Model (eg Lumina)

  Estimated annual mileage   Miles driven to work daily (each way)

  Please select any of the following that are applicable: Alarm 
  Garage Locked Private  Carport

 Vehicle Information - Vehicle #3

  Year

  Make (eg Chevrolet)

  Model (eg Lumina)

  Estimated annual mileage   Miles driven to work daily (each way)

  Please select any of the following that are applicable:  Alarm
  Garage Locked   Private    Carport

 Vehicle Information - Vehicle #4

  Year

  Make (eg Chevrolet)

  Model (eg Lumina)

  Estimated annual mileage   Miles driven to work daily (each way) 

  Please select any of the following that are applicable:  Alarm
  Garage Locked Private    Carport

 Desired Auto Insurance Coverage

 Vehicle

 Liability Limits

 Uninsured
 Motorist

 Medical

 Deductible: 
 Collision

 Deductible:
 Comprehensive

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Note:  Liability coverage limits are listed as bodily injury (BI) per person/maximum/property  damage (PD) maximum per event, e.g. 100/300/100 represents $100K per person up to $300K and $100K maximum property damage coverage.

 Drivers Information

Driver #

Name

Date of Birth

Marital Status

Gender

# of years licensed

Total # Violation s last 3 years

Total # Accidents last 3 years1

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2

 

  

  

  

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  1   Only accidents where the insured was found to be 51% or greater at fault apply here

 Additional Driver Information or Comments

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All elements of this site, including but not limited to design and forms, copyright 2004 by Advantis Insurance Svcs

Here’s just a partial list of the hundreds of insurers we can quote for you!

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