Auto Insurance

Driving on today’s roads can be a challenge each and every day. The last thing you need is to find out you don’t have the coverage you thought you had in your policy. The Perimeter Group takes the time to review your particular insurance needs and places you with the carrier that provides the right coverage at the best rate.

Not all carriers offer the same coverage, so it is important you hire an agency to help guide you to the right place to meet your needs.

The Perimeter Group…we build insurance coverage that protects you.

Personal Information

Name:*
E-mail:*
Phone:*
-
Work Phone:
-
Cell Phone:
-
Fax Number:
-
Best Time To Contact:

Garage Address

Address:*
Mailing Address:

Driver 1

Driver 1 Name:*
Driver 1 DOB:*
Driver 1 Gender:*
Driver 1 Marital Status:*
Years Licensed In US:*
Age First Licensed In Any Country:*
Driver 1 Drivers License Number:
4 Year Degree or Higher? (Specify Field):
Relationship To Applicant:

Driver 2

Driver 2 Name:
Driver 2 DOB:
Driver 2 Gender:
Driver 2 Marital Status:
Years Driver 2 is Licensed in US:
Age Driver 2 was First Licensed in Any Country:
Driver 2 Drivers License Number:
Driver 2 Four Year Degree or Higher? (Specify Field):
Driver 2 Relationship To Applicant:

Driver 3

Driver 3 Name:
Driver 3 DOB:
Driver 3 Gender:
Driver 3 Marital Status:
Years Driver 3 is Licensed in US:
Age Driver 3 was First Licensed in Any Country:
Driver 3 Drivers License Number:
Driver 3 Four Year Degree or Higher? (Specify Field):
Driver 3 Relationship To Applicant:

Driver 4

Driver 4 Name:
Driver 4 DOB:
Driver 4 Gender:
Driver 4 Marital Status:
Years Driver 4 is Licensed in US:
Age Driver 4 was First Licensed in Any Country:
Driver 4 Drivers License Number:
Driver 4 Four Year Degree or Higher? (Specify Field):
Driver 4 Relationship To Applicant:

Car 1

Year, Make, Model:*
VIN:*
Usage:*
Miles to Work / School (one way):*
Annual Mileage:*

Car 2

Car 2 Year, Make, Model:
Car 2 VIN:
Car 2 Usage:
Car 2 Miles to Work / School (one way):
Car 2 Annual Mileage:

Car 3

Car 3 Year, Make, Model:
Car 3 VIN:
Car 3 Usage:
Car 3 Miles to Work / School (one way):
Car 3 Annual Mileage:

Car 4

Car 4 Year, Make, Model:
Car 4 VIN:
Car 4 Usage:
Car 4 Miles to Work / School (one way):
Car 4 Annual Mileage:

Tickets & Accidents

Please describe any tickets or accidents in the past 5 years.

Coverages

Bodily Injury Limits:
Property Damage Limit:
Medical Payments Limit:
Uninsured Motorist Bodily Injury:
Collission Deductible:
Comprehensive Deductible:
Additional Coverage Options:
Does an employer need to be named as additional insured?

Current Insurance

Company Name:
6-Month Premium:
Expiration Date:

Questions or Comments

Anything else we should know?
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to provide you with a quote, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.*