Durkin & DeVries Insurance Insurance: Auto Quotation Form

For an Auto insurance quote for one vehicle simply fill out the form below and click the submit button. One of our agents will contact you to review a personalized quote within 24 hours. If you have any questions regarding this form or regarding coverage in general, please feel free to contact us.

This form requires you to submit a minimum of one vehicle. If you are interested in a quote for more than one vehicle please fill out the quote for multiple vehicles form.

Personal Info

First Name:

Last Name:

Address:

City:

State:

Zip Code:

E-mail:

Telephone:

Fax:

Best time to call:

Driver Information

	First Name	Last Name	Date of Birth (mm/dd/yy)	License Number	State
Driver 1
Driver 2
Driver 3
Driver 4

Vehicle Info

Year:

Make:

Model:

Vehicle I.D. #:

Annual Mileage:

Airbag/Automatic Seatbelts

Yes No

Anti-theft device?

Yes No

Lojack device?

Yes No

Age 65 and older?

Yes No

Transit or T-pass Discount?

Yes No

Coverage Options:

Part 1 - Bodily Injury to others:

$20,000/$40,000

Part 2 - Personal Injury Protection:

$8,000

Part 3 - Uninsured Motorist:

Part 4 - Property damage:

Part 5 - Optional Bodily Injury:

Part 6 - Medical Payments:

Part 7 - Collision (deductible):

Part 8 - Limited Collision:

Part 9 - Comprehensive (deductible):

Part 10 - Substitute Transportation:

Part 11 - Towing and Labor:

Part 12 - Underinsured Motorist:

Submitting an insurance quotation request to Durkin & DeVries Insurance does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Durkin & DeVries Insurance to confirm binding or altering coverage.