Low cost New Hampshire insurance from Immanuel Insurance Agency
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Immanuel insurance Agency - NH Insurance



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On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be New Hampshire)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
OPT-OUT SELECTION: We realize your time is valuable. Rather than fill in all the underwriting information below, would it be easier to have us call you? If so, you can check the "Opt-Out" box above, press the send button at the bottom of this form, and have a friendly agent call you. If possible, please have your current policy handy as this has helpful information we may need.

If you want to continue the complete online quoting process, do NOT check the box and please continue below.

Primary Insured's Occupation:
Primary Insured's Company Sponsor, if any:
Primary Insured's Education Level:
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier. If none, type No coverage)
 
What is Cost of Current Coverage
and Expiration Date?


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 5 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Describe
Vehicle Use:
If Car is Driven to Work, List
One-Way Mileage Here:
Does Driver need
an SR22 FILING?
Yes No If YES to SR22 filing, why needed?
Give details on all violations or accidents:


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 5 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Describe
Vehicle Use:
If Car is Driven to Work, List
One-Way Mileage Here:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS:
If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits - - - Liability Limits Must
Match Vehicle #1 - - -
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:


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Regular Mail
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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Immanuel Insurance Agency | PO Box 300 | 3 Brittany Lane | Barrington, NH 03825
Phone: 603-335-4300 | Fax: 603-822-7101
Email: david@immanuelins.com | Office Map/Directions | About Us |
Privacy Notice | NH Insurance License #3356286

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