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   All Risk Insurance Agency

House - Contact All Risk Insurance Agency in Southington CT, for all your insurance needs including bussines and personal property, auto, umbrella,tenats and condo policies.

 
 

Phone:  

(860) 757-3990

 Fax:    

(860) 757-3991


E-mail:
petulia@all-riskins.com
 

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Auto Quote Form
Personal Information
Name:
 Referred By/Source:
Address:
Home Phone:
 Mobile/Work Phone:
Current Insurance Co.:

 Ex. Date:
 		Premium:

Drivers Information
1 - Name:
DOB:
 		DL#:
  
Use:
 		Miles One Way:
 Martial Status:
2 - Name:
DOB:
 		DL#:
  
Use:
 		Miles One Way:
 Martial Status:
3 - Name:
DOB:
 		DL#:
  
Use:
 		Miles One Way:
 Martial Status:
4 - Name:
DOB:
 		DL#:
  
Use:
 		Miles One Way:
 Martial Status:

Vehicles Information
1 - VIN#:
Year:
 		Make:
 Model:
2 - VIN#:
Year:
 		Make:
 Model:
3 - VIN#:
Year:
 		Make:
 Model:
4 - VIN#:
Year:
 		Make:
 Model:

Current/Requested Coverage
Split Limit Liability
250/500/100 100/300/100 50/100/50 25/50/25

Single Limit
100 300 500  

UM/UIM
250/500 100/300 50/100 25/50

MED
10,000 5,000 2,000 1,000

Comp. Deductible
(Check the corresponding vehicle number.)
50
100
250
500
1000
None
1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4
Collision Deductible
(Check the corresponding vehicle number.)
50
100
250
500
1000
None
1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4		 1
2
3
4

Towing Rental Reimbursement
Yes No Yes No

Accidents/Violations (in the past 5 years)