Lanza Insurance Agency - Personal Auto Quote

Lanza Insurance Agency - South Windsor, Connecticut's Insurance Agency - SouthWindsorInsurance.com

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Personal Auto Quote

There are several ways to get a Personal Auto Insurance Quote from us:

The fastest way to receive an Auto Insurance Quote is to call us at 860.282.7777.
You can Contact Us and request an Auto Insurance Quote. A representative from our agency will contact you directly.
You can fax us a copy of your Current Auto Policy (Declaration Pages) and we will contact you with a quote. Our fax number is 860.282.0009.
You can Email Us a copy of your Current Auto Policy (Declaration Pages) and we will contact you with a quote.
Fill out the form below and we will provide you with an Auto Insurance Quote within 1-2 business days.

No coverage is bound by completing this quote request or by receiving a quote. Coverage can only be bound once a payment along with a signed dated application is received by our agency.

We may need to contact you for additional information in relation to your request. This quote is based on the information you have provided us and is subject to additional underwriting and verification.

* Required Field

Name*:

Address*:

City*:

State*:

Zip Code:

Phone*:

Email:

Best Way to Contact You:

Number of Years at Residence:

If Less Than 6 Months, Previous Address:

Occupancy:

Residence:

Do You Currently Have Homeowner or Renter's Insurance?:

Occupation:

Current Auto Coverage:

If 'No', Please Provide Reason:

Years with Current Company:

Current/Prior Insurance Company:

Expiration/Cancellation/Non-Renewal Date:

(mm/dd/yyyy)

Please select the Liability Limits that are closest to your current auto policy or enter them below if they are not listed.

Liability Limits:

Other:

Drivers

Number of Drivers in Household:
If More Than 5 Drivers, Please Contact Us.

Driver 1

Name*:
Date Of Birth*:	(mm/dd/yyyy)
Drivers License Number*:
Date First Licensed In US If Less Than 4 Years:	(mm/dd/yyyy)
Marital Status:

Vehicles

Number of Vehicles:
If More Than 5 Vehicles, Please Contact Us.

Vehicle 1
Year*:
Make*:
Model*:
Vehicle Identification Number*:
Principal Operator*:
Ownership:
Anti-Theft Device:
Commute To/From Work Miles:
Approximate Annual Miles:
Vehicle Kept:
Coverages
Comprehensive Deductible:
Full Glass:
Collision Deductible:
Towing:
Rental Reimbursement:
Vehicle Use:

Vehicle 2
Year*:
Make*:
Model*:
Vehicle Identification Number*:
Principal Operator*:
Ownership:
Anti-Theft Device:
Vehicle Use:
Commute To/From Work Miles:
Approximate Annual Miles:
Vehicle Kept:
Coverages
Comprehensive Deductible:
Full Glass:
Collision Deductible:
Towing:
Rental Reimbursement:

Vehicle 3
Year*:
Make*:
Model*:
Vehicle Identification Number*:
Principal Operator*:
Ownership:
Anti-Theft Device:
Vehicle Use:
Commute To/From Work Miles:
Approximate Annual Miles:
Vehicle Kept:
Coverages
Comprehensive Deductible:
Full Glass:
Collision Deductible:
Towing:
Rental Reimbursement:

Vehicle 4
Year*:
Make*:
Model*:
Vehicle Identification Number*:
Principal Operator*:
Ownership:
Anti-Theft Device:
Vehicle Use:
Commute To/From Work Miles:
Approximate Annual Miles:
Vehicle Kept:
Coverages
Comprehensive Deductible:
Full Glass:
Collision Deductible:
Towing:
Rental Reimbursement:

Vehicle 5
Year*:
Make*:
Model*:
Vehicle Identification Number*:
Principal Operator*:
Ownership:
Anti-Theft Device:
Vehicle Use:
Commute To/From Work Miles:
Approximate Annual Miles:
Vehicle Kept:
Coverages
Comprehensive Deductible:
Full Glass:
Collision Deductible:
Towing:
Rental Reimbursement:

Comments:

P.O. Box 646 • 524 Sullivan Avenue • South Windsor, CT 06074
Phone: 860.282.7777 • Fax: 860.282.0009

www.lanzaagency.com • www.lanzainsuranceagency.com • www.southwindsorinsurance.com

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