Liverstone Insurance Agency

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Quote Request Form

We could save you $1,000 a year or more!

To get the most accurate quote, Please fill in all of the fields below
Note: For a fast quote, you do not have to provide drivers license or VIN numbers, but we will need those in order to finalize your quote premium.

We handle all types of insurance.

Please provide the following contact information:

Name To Put On Policy	*REQUIRED
Street Address	(No PO Box, please)
Years at above	(if less than 3, please provide previous full address in comments box below)
Mailing Address	(if different)
City
State
Zip code
Home Phone	*REQUIRED
Work Phone	*REQUIRED
Email Address	*REQUIRED (required to return quote!)
Occupation
Employer
Years at above

What is your desired effective date for this coverage?

Enter the total number of people age 16+ in the household:
Please provide the below needed information for all people age 16+ in the household:
If any person needs to be excluded from coverage, please describe in comments further below

Drivers 1 through 4	Full Name	Gender	Marital Status	Date of Birth	Driver's License # and State	Number of Violations (claims, tickets or accidents) within past five years
Driver 1
Driver 2
Driver 3
Driver 4

Is any driver required to file a State Financial Responsibility/SR22 Form? Yes No Don't Know
Are there any other driving age residents in household? Yes No

For each incident, please indicate the type of claim, ticket and/or accident
(e.g. At fault accident, not at fault accident, DUI, open container, reckless driving, careless driving,
speeding [with # miles over limit], failure to yield, type and amount of insurance claim, or other moving violations):

	Incident/Claim Type & Amount	Date: (MM/DD/YY)	Driver
Violation 1
Violation 2
Violation 3

Are you currently insured? Yes No

If Yes, with what company (not agency):
Approximate current six-month premium: $

If No, when was the last date you had insurance:

Please provide the below needed information for all vehicles:

Autos 1 through 4	Year:	Make:	Model:	Loan On Auto?	Comp & Collision Desired	VIN, if known (Vehicle Identification Number - will need for final quote - this is on your current insurance ID card)
Auto 1
Auto 2
Auto 3
Auto 4

Is any vehicle used for delivery? Yes No

Primary Vehicle use?
Is there damage to any vehicle? Yes (describe in comments, below) No
Are there any other vehicles in the household? Yes (describe in comments, below) No

Select the coverages you currently have/prefer, only liability is required:
NOTE: If your current liability coverages are lower than what you select, please describe in comments below

Liability (Person/Accident/Property)	Medical	Optional Coverages
$30 K / $60 K / $10 K (Minnesota Minimum) - That's $30,000 per person for injuries you cause to the other party, up to $60,000 for all, and $10,000 for damage you cause to the other party's property. $50 K / $100 K / $25 K $50 K / $100 K / $50 K $100 K / $300 K /$ 50 K $250 K / $500 K / $100K $100 K Combined Single Limit $300 K Combined Single Limit If other limits desired, describe below	Decline $1,000 $2,000 $5,000 $10,000	Uninsured Motorist (UM) Bodily Injury (injury to people in your vehicle) Uninsured Motorist Property Damage (damage to your car/property) UM Stacked (additive from all vehicles) -or- UM Non-Stacked Rental Reimbursement $20/day Rental Reimbursement $30/day Rental Reimbursement $40/day Towing/Roadside Assistance Original Manufacturer Replacement Parts $0 glass deductible Custom/Special Equipment (describe below)

Is this a business auto quote? Yes (All autos registered in name of the business)
If business auto, name of business:
If business auto, type of business:
If business auto, legal structure of business:
If business auto, Federal Tax ID # of business:

Select any of the following applicable DISCOUNTS:

I am a college graduate (bachelors degree or higher, describe below)

I own a home (not just a mobile home)

I own a Mobile Home

Airbags (driver only - specify which car, below)

Airbags (driver and passenger - specify which car, below)

Anti-lock brakes (specify which car below)

Anti-theft device (please indicate car & describe. Proof will be required)

Good Student (3.0+ GPA. Proof will be required)

Student Away At School (occasional driver)

Mature Safe Driver Course (Age 55+, within 3 years of course completion. Proof required)

I will pay six months in full up front (up to 10% off)

I will pay in installments by Automatic Deduction (EFT) from my bank (up to 5% off)

I will pay for/sign this policy at least 8 days before effective date (up to 5% off)

Please enter any additional comments, such as a fifth+ automobile, fifth+ driver, drivers to exclude, RV or motorcycle, name & address of the bank who has loan(s) on vehicles, different limits on comprehensive v collision, difference between current coverage and desired coverage, or clarification/more information on items above. If any car is not registered in your name, indicate why:

In order to give you the least expensive quote, we will need your Social Security Number.
We understand that this is sensitive information, and can receive it on the phone.
If you prefer a faster quote, please enter it in the box below:
Social Security #

In order to prepare an insurance quote for you, we will need to check specific information about you, including VIN, MVR, CLUE and credit reports (not credit "inquiries"), with insurance companies. By submitting this form, you hereby agree that it is allright for us to run these checks and provide you with an insurance quote. Credit checks for insurance qualification do not count negatively as an "inquiry" on your credit report.

Lowest Auto Insurance Rates Quote

Automobile Insurance, Car Insurance, Property Insurance, Homeowner's Insurance, Medical Insurance and Business Insurance are other names by which the above types of insurance are often referenced. We also offer Travel Insurance, Errors and Omissions, Liability and special coverages. Please contact the office in your state for more information.

Liverstone Insurance Agency
119 6th Street SW
Rochester Minnesota 55902
(507) 529-1999
fax: same number

P. O. Box 9153
Rochester Mn 55903

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