Classic Auto Insurance
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
| First Name
Required
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| Last Name
Required
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| Street
Required
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| City
Required
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| State
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| ZIP / Postal Code
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| Primary Phone Number
Required
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| E-Mail Address
Required
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| Date of Birth
Required
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| Social Security Number
Optional
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| Marital Status
Required
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| Spouse First Name
Optional
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| Spouse Last Name
Optional
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| License (State, Number)
Optional
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| Accidents or Violations? Please Explain
Optional
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| Do you rent or own your home?
Optional
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| Do you currently have insurance?
Optional
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| Current Insurance Provider
Optional
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| If no, when did you last have insurance?
Optional
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| Vehicle Information |
| Year
Required
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| Make
Required
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| Model
Required
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| VIN #
Optional
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| Coverage Options |
| Comprehensive Deductible
Optional
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| Collision Deductible
Optional
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| Bodily Injury Liability
Required
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| Property Damage Liability
Required
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| Towing
Optional
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| Rental
Optional
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| How many miles will you drive your car annually? (Approximately)
Optional
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| Current Value
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
online privacy policy we will not resell your information to any third-party.
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