Quotes--Automobile Insurance

We would welcome the opportunity to provide you with a free, no obligation price quote for your automobile insurance. As an independent agent, we are able to compare a number of different insurance providers to make sure you receive the best price and the right amount of automobile insurance for your budget and your unique situation.


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Insured Information

Insured Name*
Address
City
State
ZIP Code*
Telephone
Date of Birth (MM/DD/YYYY)*
Email*

Current Insurance Coverage

Do you presently have Auto Insurance?*  Yes  No
Company Name

Bodily Injury Liability*
Property Damage Liability*
Medical Payments
Uninsured Motorist Liability*
Comprehensive Deductible*
Collision Deductible*
Rental Reimbursement Yes  No
Towing & Labor Yes  No

Licensed Drivers

Primary Driver (Applicant)

Name on License
Driver's License State
Driver's License ID Number
Date of Birth
Gender Male     Female
Marital Status Married
Single
Divorced
Widowed
Driver Training Yes  No
Tickets and Accidents (last 5 years)

Secondary Driver

Name on License
Driver's License State
Driver's License ID Number
Date of Birth
Gender Male     Female
Marital Status Married
Single
Divorced
Widowed
Relationship to Applicant
Driver Training Yes  No
Tickets and Accidents (last 5 years)

Please provide the names and birthdates of any other residents in your household licensed to drive.


Other Drivers

Name Date of Birth Drivers License ID Number
1.
2.
3.

Vehicle Information
First Vehicle
Year*
Make*
Model*
Vehicle Identification Number (VIN)
License State

Second Vehicle
Year
Make
Model
Vehicle Identification Number (VIN)
License State

How did you hear about us?*  

 

C. John Crane, Inc.--Your Peace of Mind is Our Business.


C. John Crane, Inc.    670 Abbott Road    Buffalo, NY 14220    t:716.823.6230    f:716.824.5808