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1
of
2
- Existing Coverage
50%
Existing Coverage
Do you currently have auto insurance?
*
Yes
No
Please upload a copy of your existing auto policy
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Personal Information
We just need to know a little bit about you so we can contact you with your quote once you've completed the form.
Your Name
*
First
Last
Your Email
*
Your Phone
*
How do you prefer we contact you with your quote?
Call
Email
Text
No Preference
Full Names and dates of birth of ALL drivers on the policy
*
License numbers of all drivers
*
Did any driver have their license in another state or country previously?
Yes
No
Please list the driver, state or country, and date first licensed:
*
Please upload a photo of your out of state/country drivers license and or driving record:
Having this information allows us to give you credit for your out of state driving experience which will give you the most competitive rate.
Drop files here or
Select files
Max. file size: 100 MB.
Vehicle Identification Numbers (VIN) of all cars, if available
What address will the car(s) be parked?
*
What would you like your deductible to be?
*
300
500
1000
Unsure
Will you need....
*
Rental Car Coverage
Towing and Labor Coverage
GAP Coverage
Accident Forgiveness
None
Do you have AAA?
*
Yes
No
Please enter your AAA membership number if you have it available, as well as your AAA member since date:
Does anyone on your policy drive any vehicle for a ride sharing network?
Yes
No
(Uber, Lyft, Doordash, Etc.)
Which driver/company/vehicle?
Please list the NAME of the person who referred you to Berlin Insurance. The name of the source is EXTREMELY important to get you sent over to the correct department, and will help you get the quote as soon as possible.
*
First
Last
If you were referred to a specific sales representative, please list their name here:
Any additional notes, questions, or concerns?
Comments
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