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Low cost Indiana, Michigan, and Ohio homeowners insurance quotes from Shuttleworth Insurance.com
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    Your Personal Data

    Your Name:
    Street Address:
    City:
    State:
    Zip Code:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
    Primary Insured's Occupation:
     
    Marital Status:
    Single Married
    Homeowner?
    Yes No
     
    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)


    DRIVER INFORMATION #1
    Name: Birthdate:
    Sex (M/F): # Years U.S.
     Licensing:
    Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
    Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
    Number & Type of MAJOR violations last 3 years: Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?
    Yes No If YES to SR22 filing, why needed?
    (list accident/cite)


    DRIVER INFORMATION #2 (if none, leave blank)
    Name: Birthdate:
    Sex: # Years U.S.
     Licensing:
    Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
    Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
    Number & Type of MAJOR violations last 3 years: Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?
    Yes No Comments or
    Remarks?
    If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:


    VEHICLE #1 INFORMATION
    (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
    Year of vehicle: Make & Model:
    Vehicle ID# (for rating accuracy):
    Annual Mileage: Used in business?
    (Explain, if yes):
    VEHICLE #1 COVERAGES:
    Select Liability Limits
     
    Select Comprehensive Deductible:
     
    Select Collision Deductible:
     
    Uninsured Motorists
    Coverage?
    YES NO
     
    Rental Car &
    Towing Coverage?
    YES NO
     
    Medical and/or
    PIP Coverage?
    YES NO
     
     
    VEHICLE #2 INFORMATION (if none, leave blank)
    Year of vehicle: Make & Model:
    Vehicle ID# (for rating accuracy):
    Annual Mileage: Used in business?
    (Explain, if yes):
    VEHICLE #2 COVERAGES:
    Select Liability Limits - - - Liability Limits Must
    Match Vehicle #1 - - -
     
    Select Comprehensive Deductible:
     
    Select Collision Deductible:
     
    Uninsured Motorists
    Coverage?
    YES NO
     
    Rental Car &
    Towing Coverage?
    YES NO
     
    Medical and/or
    PIP Coverage?
    YES NO
     
    Comments or Remarks:
    (List additional drivers, autos, etc. here)
    If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:


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