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Request Auto Insurance Quote

For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only.

Please note that no coverages can be changed, altered or bound through this form.

General Information
Name:
Address:
City:

 
State:
Zip:
County:
Email:
Phone Day:

 
Phone Night:
Best time to call:
AM   PM  

Current Auto Insurance Company (not agency)
Company Name:
Policy Exp. Date:
Are you currently Insured?
Yes   No
 
Premium:
Term:
6 months   1 Year   Other   

Vehicle Information
Include all cars you or your family members own or lease
CAR #1
Year:

 
Make:
Model: (specific XL, GT, etc.)
Driver Name:

 
Collision Coverage?
Yes   No  
Comprehensive Coverage?
Yes   No
 
Use:
Pleasure
School
Work
Station
Business
 
# miles one way:
Additional Vehicle Information
Towing?
Yes   No
 
Rental?
Yes   No
Airbags?
Yes   No
 
Anti-Theft Devices?
Yes   No
 
 
CAR #2
Year:

 
Make:
Model: (specific XL, GT, etc.)
Driver Name:

 
Collision Coverage?
Yes   No  
Comprehensive Coverage?
Yes   No
 
Use:
Pleasure
School
Work
Station
Business
 
# miles one way:
Additional Vehicle Information
Towing?
Yes   No
 
Rental?
Yes   No
Airbags?
Yes   No
 
Anti-Theft Devices?
Yes   No
 
 
CAR #3
Year:

 
Make:
Model: (specific XL, GT, etc.)
Driver Name:

 
Collision Coverage?
Yes   No  
Comprehensive Coverage?
Yes   No
 
Use:
Pleasure
School
Work
Station
Business
 
# miles one way:
Additional Vehicle Information
Towing?
Yes   No
 
Rental?
Yes   No
Airbags?
Yes   No
 
Anti-Theft Devices?
Yes   No
 

Driver Information
Driver's Name
 
Relation to you Date of Birth
(MM/DD/YY)
Male/
Female
Married/
Single
Completed # yrs
licensed
Drivers
Education
Course
Accident
Prevention
Course
self M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N

Driver History

Has any driver been convicted of any moving traffic violations in the past 3 years (including DWI and Driving While Suspended)?    Yes   No

Has any driver had his/her license suspended or revoked?    Yes   No

Has any driver listed been involved in any accidents, regardless of fault, in the past 3 years?    Yes   No

For any questions answered 'Yes' please provide details in the space provided:

 


Coverage Options
Liability / Bodily Injury
and Property Damage

 
Tort Threshold Option Collission Deductible Comprehensive Deductible
$100,000
$300,000
$500,000
No Tort Threshold
No Tort Threshold (verbal)
 
$250
$500
Other
$250
$500
Other

 

Kleeber Insurance Services, established in 1851, is a subsidiary of Kinderhook Bank Corporation, the holding company for Kinderhook Bank.

*Insurance products are not a deposit or an obligation of, or guaranteed by, Kinderhook Bank. Not FDIC insured.