Germain Insurance Agency - Request Auto Quote

Request an Auto Quote
If you would like a quote please call one of our locations or email us your information. For quotes on other insurance products, please call to speak to an agent directly. If you wish to contact us by email, please fill out the following information. Please be aware we will need to contact you by phone to get further information to confirm quotes. This is not a secure website.

OWNER OF VEHICLE/NAME INSURED

First:

MI:

Last:

Age:

Marital Status:

ADDITIONAL DRIVERS/HOUSEHOLD MEMBERS
1st Member

First:

MI:

Last:

Age:

Marital Status:

2nd Member

First:

MI:

Last:

Age:

Marital Status:

3rd Member

First:

MI:

Last:

Age:

Marital Status:

VEHICLE INFORMATION
1st Vehicle

Year:

Make:

Model:

# of Doors:

2WD/4WD:

Zip Code where

Garaged/Stored:

2nd Vehicle

Year:

Make:

Model:

# of Doors:

2WD/4WD:

Zip Code where

Garaged/Stored:

3rd Vehicle

Year:

Make:

Model:

# of Doors:

2WD/4WD:

Zip Code where

Garaged/Stored:

4th Vehicle

Year:

Make:

Model:

# of Doors:

2WD/4WD:

Zip Code where

Garaged/Stored:

CURRENT INSURANCE INFORMATION
Name of Current Insurance Company:

Effective Date of Policy:

dd/mm/yyyy

Expiration/Cancellation Date of Policy:

dd/mm/yyyy

Current Limits of Liability:

Current Deductible Values:

Do you pay in full or make monthly payments?

Do you have current home or renters insurance?

Please list any traffic violations or accidents including date of incedent in
the last 5 years for any listed driver:

Please list and describe any damage on the vehicle:

CONTACT INFORMATION
Phone number where you can be reached:

E-mail Address:

Best time to call: