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Request a Free Auto Insurance Quote

Get a personalized auto insurance quote in just a few minutes. Please fill out the information below as accurately as possible.

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Request a Free Auto Insurance Quote

Get a personalized auto insurance quote in just a few minutes. Please fill out the information below as accurately as possible.

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Request a Free Auto Insurance Quote

Get a personalized auto insurance quote in just a few minutes. Please fill out the information below as accurately as possible.

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1. Contact Information

Primary Contact Full Name

Email Address:

Phone Number:

Current Home Address:

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2. Driver Information

Please list everyone living in your household.

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Driver 1 (Primary)

Full Name:

Date of Birth:

Driver’s License Number:

Have you had any accidents or tickets within the last 3 years?

No

Yes

If yes, please provide brief details/dates:

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Driver 2

Full Name:

Date of Birth:

Relationship to Primary Contact:

Driver’s License Number:

Have they had any accidents or tickets within the last 3 years?

No

Yes

If yes, please provide brief details/dates:

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Driver 3

Full Name:

Date of Birth:

Relationship to Primary Contact:

Driver’s License Number:

Have they had any accidents or tickets within the last 3 years?

No

Yes

If yes, please provide brief details/dates:

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Driver 4

Full Name:

Date of Birth:

Relationship to Primary Contact:

Driver’s License Number:

Have they had any accidents or tickets within the last 3 years?

No

Yes

If yes, please provide brief details/dates:

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3. Vehicle Information

Please provide details for each vehicle you want to insure.

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Vehicle 1

Year:

Make:

Model:

Vehicle Identification Number (VIN):

Commute: How many miles do you drive this vehicle one way to work?

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Vehicle 2

Year:

Make:

Model:

Vehicle Identification Number (VIN):

Commute: How many miles do you drive this vehicle one way to work?

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Vehicle 3

Year:

Make:

Model:

Vehicle Identification Number (VIN):

Commute: How many miles do you drive this vehicle one way to work?

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Vehicle 4

Year:

Make:

Model:

Vehicle Identification Number (VIN):

Commute: How many miles do you drive this vehicle one way to work?

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4. Coverage Preferences

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Physical Coverages (Deductibles)

Select your preferred deductible for your vehicle(s):

Comprehensive Coverage (Protection against theft, fire, glass damage, animal hits, etc.)

$250 Deductible

$500 Deductible

$1,000 Deductible

Decline Coverage

Broad Form Collision Coverage (Protection if you are in an accident)

$250 Deductible

$500 Deductible

$1,000 Deductible

Decline Coverage

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Personal Injury Protection (PIP)

Medical Coverage Options: Do you want Unlimited Personal Injury Protection, or lower limits?

Unlimited PIP Coverage (Highest level of protection)

Lower Limits (An agent will contact you to discuss your options and required waivers)

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Disclaimer: Submitting this form does not bind coverage. All quotes are subject to verification of driving records and vehicle history.

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Auto Insurance

Home Insurance

Business Insurance

Visit Us

4752 Occidental Hwy.

Adrian, MI 49221

Contact Us

Phone: (517) 423-8316

Fax: (517) 423-6280

Business Hours

Mon - Thu: 8:30 am - 5:00 pm
Friday: 8:30 am - 4:30 pm
Sat - Sun: Closed

Auto Insurance

Home Insurance

Business Insurance

Visit Us

4752 Occidental Hwy.

Adrian, MI 49221

Contact Us

Phone: (517) 423-8316

Fax: (517) 423-6280

Business Hours

Mon - Thu: 8:30 am - 5:00 pm
Friday: 8:30 am - 4:30 pm
Sat - Sun: Closed

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All Rights Reserved | Hayes Insurance Agency

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