Quote Form
Please answer each question that applies to you fully and click "submit" to send to an agent at B.R.Knuckles Insurance. We appreciate the opportunity to service your insurance needs.
Name:
Phone Number and Email
How do you prefer to be contacted?
Are there any other drivers in your household?
Clear selection
If you answered "yes" to the previous question, list Name/DOB/Driver's License Number of said driver(s).
Date of Birth
MM
/
DD
/
YYYY
What is your driver's license number?
What is your occupation?
What is your mailing address?
What is your street address?
How long have you lived there?
If you have lived there less than 2 years, what was your prior address?
Do you own your home or rent it? Rent
Have any household drivers been involved in at-fault accidents or been convicted of moving violations in the last 3 years?
Clear selection
If you answered "yes" to the previous question, please explain here.
What company currently provides your auto insurance?
What coverage are you interested in?
Would you like rental car and roadside assistance coverage?
Clear selection
Some of our companies offer a "paperless" discount. Is this something you would be interested in?
Clear selection
How would you like to pay your premium?
Clear selection
Would you be interested in paying by EFT if there is a discount involved?
Clear selection
Please list the year, make, model, and VIN for each of your vehicles. Also, state whether you would like full coverage, liability + comprehensive, or liability only coverage for each vehicle.
Submit
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