Home Custom Quote – Langlois Insurance Agency

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Phone*

Coverage Effective Date:

Vehicle information

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Add Another Vehicle?

Yes
No

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Add Another Vehicle?

Yes
No

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Add Another Vehicle?

Yes
No

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Add Another Vehicle?

Yes
No

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Add Another Vehicle?

Yes
No

Year*

Make*

Model*

VIN*

Vehicle uses

Name on title*

Loan/lease company

Ownership*

Lease
Loan
Own

Comprehensive & collision coverage?*

Yes
No

Is this vehicle used for any business purpose including ride sharing services?*

Yes
No

Driver information

Driver's name*

Date of birth*

Drivers License #*

Marital Status*

Single
Married

Annual mileage*

Miles (estimated)

Has completed driver training
Qualifies for the good-student discount

Accidents or violations in past 5 years

include date and type of incident

Add Another Driver?

Yes
No

Driver's name*

Date of birth*

Drivers License #*

Marital Status*

Single
Married

Annual mileage*

Miles (estimated)

Has completed driver training
Qualifies for the good-student discount

Accidents or violations in past 5 years

include date and type of incident

Coverage information

Do you currently have auto insurance, or have you had it within the last six months?

Yes
No

Liability & Uninsured Motorist*

Comprehensive Deductible*

Collision Deductible*

Coverage options

GAP / replacement cost
Medical payments (1,000)
Medical payments (5,000)
Medical payments (10,000)
Rental reimbursements
Towing & roadside assistance

Comments

How Did You Find Us?*

Insurance score agreement

In order to obtain this quote, an insurance score may be ordered by one or more insurance companies during the rating process. By checking the box, you are authorizing Landers Insurance Agency, Inc and/or its insurance company partners to order this score as needed in conjunction with obtaining the requested quote.

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Driver information

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