Southeastern Insurance Quotes

GET A QUOTE FOR: Auto | Home | Life/Health | Commercial

*AUTO INSURANCE QUOTE*
*Personal Information*
*Name*
*Address*
*City*		*State*		*Zip*
*Home Phone*		*Work Phone*
*E-mail Address*			*Current Auto Insurance Company*
*Renewal Date*				*Own Home? Y N*
*Security Question:*	Type the characters above

*Vehicles*
*Vehicle #*	Yea r (00)	*Make*	*Model*	*2dr/4dr*	*Miles to Work (one way)*	*Annual Mileage*	*Comprehensive* *Deductible*	*Collision Deductible*	*Towing / Labor*	*Loss of Use?*
1.									*Yes*	*Yes*
2.									*Yes*	*Yes*
3.									*Yes*	*Yes*

*Drivers*
*Driver's Name*	*Date of Birth*	*Gender*	*Marital Status*	*Moving Violations ( Last 3 Yrs)*	*Accidents ( Last 3 Yrs)*
		*Male Female*	*Married* *Single* *Divorced*
		*Male* *Female*	*Married* *Single* *Divorced*
		*Male* *Female*	*Married* *Single* *Divorced*

*Liability Limit for All Cars*
*Choose either Bodily Injury & Property Damage OR*			*Single Limit*
*Bodily Injury*	*Property Damage*	*OR JUST CHOOSE ONE OF THESE: ---->*	Single Limit choose one
*None*	*None*		*None*
*25,000/50,000*	*25,000*		*60,000*
*50,000/100,000*	*50,000*		*100,000*
*100,000/300,000*	*100,000*		*300,000*
*250,000/500,000*	*500,000*		*500,000*

This is not an application for insurance and does it obligate this agency to issue any policy of insurance.

Southeastern Insurance, P.O. Box 205, 4 Village Drive, Batesville, Indiana 47006
(812) 934-3209 | 1-877-934-3209 | Fax (812) 934-6160 | info@southeastern-ins.com

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