Inter-Agency Insurance Service, Inc.

We offer a variety of coverages based on your specific needs. If you have a good driving record we have very competitive auto rates. Fill out the preliminary form below and one of our agents will contact you.

Name

Address

City

State

Zip

Phone

Married Yes No

E-mail

How Long Employed?

Occupation

Children

Yes No

If yes, Names and Ages

How long at current address?

Current Insurance Company

Any claims / losses in the last three years?

Driver Name	Date of Birth	Drivers License #	Social Security #	# Tickets / Accidents

Limit of Liability	$60,000	$100,000	$300,000	$500,000
Medical Payments	$1,000	$2,000	$5,000	$10,000
Uninsured Motorist	$60,000	$100,000	$300,000	$500,000
Comprehensive Ded.	$100	$250	$500	$1000
Collision Ded.	$100	$250	$500	$1000
Towing	Yes No		Rental Car	Yes No

	Year	Make	Model	VIN	Use*	Driver
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Vehicle #5
Vehicle #6
* Use: Pleasure, Driver to work and number of miles to work one-way or Business Use.