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Automotive Insurance
- Online Quote
Fill out and submit the form below
and a Georgelas Financial Service Corporation representative will contact you
at the email address you provide below.
Primary insured
Applicant Name
Email address
*
(required for contact)
Date of Birth
Address
Driver's Licence #
Occupation
Citations/Accidents
Prior Carrier
Duration / how long
Name and phone numbers of all contacts
1. name
phone
2. name
phone
3. name
phone
4. name
phone
5. name
phone
Other Drivers in Household
Drivers in HH
select one
0
1
2
3
4
OTHER THAN MYSELF
Name of driver 2
Relation to applicant
Date of Birth
Address
Driver's Licence #
Occupation
Citations/Accidents
"Good student"
(GPA 3.0 or better)
Yes
No
Name of driver 3
Relation to applicant
Date of Birth
Address
Driver's Licence #
Occupation
Citations/Accidents
"Good student"
(GPA 3.0 or better)
Yes
No
Name of driver 4
Relation to applicant
Date of Birth
Address
Driver's Licence #
Occupation
Citations/Accidents
"Good student"
(GPA 3.0 or better)
Yes
No
Name of driver 5
Relation to applicant
Date of Birth
Address
Driver's Licence #
Occupation
Citations/Accidents
"Good student"
(GPA 3.0 or better)
Yes
No
Vehicle Information
Vehicles in HH
select one
0
1
2
3
4
5
Car 1 - VIN #
Please enter the vehicle's Vin # -OR- the vehicle's year, make, model, model type, abs, and passive restraints (seatbelts).
Year
Make
Model
Model Type ( Extra Cab / 4wd / 2wd / 1ton / etc )
ABS
Yes
No
Passive Restraints
Yes
No
Coverage
select one
Full (collision & liability)
Liability only
If Motorcycle
CCs
Motorcycle's value $
Car 2 - VIN #
Please enter the vehicle's Vin # -OR- the vehicle's year, make, model, model type, abs, and passive restraints (seatbelts).
Year
Make
Model
Model Type ( Extra Cab / 4wd / 2wd / 1ton / etc )
ABS
Yes
No
Passive Restraints
Yes
No
Coverage
select one
Full (collision & liability)
Liability only
If Motorcycle
CCs
Motorcycle's value $
Car 3 - VIN #
Please enter the vehicle's Vin # -OR- the vehicle's year, make, model, model type, abs, and passive restraints (seatbelts).
Year
Make
Model
Model Type ( Extra Cab / 4wd / 2wd / 1ton / etc )
ABS
Yes
No
Passive Restraints
Yes
No
Coverage
select one
Full (collision & liability)
Liability only
If Motorcycle
CCs
Motorcycle's value $
Car 4 - VIN #
Please enter the vehicle's Vin # -OR- the vehicle's year, make, model, model type, abs, and passive restraints (seatbelts).
Year
Make
Model
Model Type ( Extra Cab / 4wd / 2wd / 1ton / etc )
ABS
Yes
No
Passive Restraints
Yes
No
Coverage
select one
Full (collision & liability)
Liability only
If Motorcycle
CCs
Motorcycle's value $
Car 5 - VIN #
Please enter the vehicle's Vin # -OR- the vehicle's year, make, model, model type, abs, and passive restraints (seatbelts).
Year
Make
Model
Model Type ( Extra Cab / 4wd / 2wd / 1ton / etc )
ABS
Yes
No
Passive Restraints
Yes
No
Coverage
select one
Full (collision & liability)
Liability only
If Motorcycle
CCs
Motorcycle's value $
Coverage Information
Liability Limits Wanted
$
select one
25,000 per person 50,000 max
50,000 per person 100,000 max
100,000 per person 300,000 max
25,000 per person 50,000 max
+1,000,000
Lien holder
Yes
No
Lease
Yes
No
Comprehensive Deductible
$
select one
0
50
120
250
500
750
1,000
1,500
Glass
Yes
No
Collision Deductible
$
select one
0
50
120
250
500
750
1,000
1,500
Include towing
Yes
No
Include car rental
Yes
No
Extras
Provide item(s) and value(s)
Interested in Electronic Draft?
Yes
No
Will you pay the premium in full?
Yes
No
1842 So. Main Street - Salt Lake City, UT 84115 | 801.487.8661 |
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