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Michigan Residents Only!
Vehicles
Coverages
Drivers
Submit
Do you currently have insurance?
Required
No, I have not had a vehicle
No, But I have had a vehicle registered
Yes, Continuous coverage for less than 1 year
Yes, Continuous coverage for 1 - 3 years
Yes, Continuous coverage for 3+ years
Number of Vehicles
Required
1
2
3
4
5+
Vehicle 1 Year Model
Required
2020
2019
2018
2017
2016
2015
2014
2013
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1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Vehicle 1 Make/Model
Required
Vehicle 1 VIN
Optional
Full Coverage?
Required
Yes
No
Comprehensive Only
Vehicle 2 Year Model
Optional
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1988
1987
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1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
Vehicle 2 Make/Model
Optional
Vehicle 2 VIN
Optional
Full Coverage?
Optional
Yes
No
Comprehensive Only
Vehicle 3 Year Model
Optional
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1995
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1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
Vehicle 3 Make/Model
Optional
Vehicle 3 VIN
Optional
Full Coverage
Optional
Yes
No
Comprehensive Only
Vehicle 4 Year Model
Optional
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
Vehicle 4 Make/Model
Optional
Vehicle 4 VIN
Optional
Full Coverage?
Optional
Yes
No
Comprehensive Only
Comprehensive Deductible
Optional
$0
$100
$250
$500
$750
$1000
Collision Deductible
Optional
$100
$250
$500
$750
$1000
Collision Type
Optional
Not Sure
Limited
Standard/Regular
Broad Form
Current Liability Coverage
Required
Not Sure
20,000/40,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
500,000/1,000,000
All drivers covered by medical insurance?
Required
Yes
No
All drivers covered by your workers compensation policy?
Required
Yes
No
Total number of employees?
Required
Number of Drivers
Required
Driver 1 (Full Name)
Required
Date of Birth
Required
January
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1911
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1901
1900
Driver 2 (Full Name)
Optional
Date of Birth
Optional
January
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1900
Driver 3 (Full Name)
Optional
Date of Birth
Optional
January
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1911
1910
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1907
1906
1905
1904
1903
1902
1901
1900
Driver 4 (Full Name)
Optional
Date of Birth
Optional
January
February
March
April
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August
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1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Tickets/Accidents in last 3 years? (List driver, date, & violation)
Optional
Owner/Officer Information
First Name
Required
Last Name
Required
Company Name
Required
Year Business Established
Required
How many years at current address?
Required
Less than 1 year
1-2 years
3 or more years
Street Address
Required
City
Required
ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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Preferred Method of Contact
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Phone
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