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  QUOTE my AUTO Insurance
(OHIO, PENNSYLVANIA, MICHIGAN, TEXAS, & FLORIDA RESIDENTS ONLY)
Please take a few moments to complete this form for a FREE AUTOMOBILE INSURANCE QUOTE. Completion of this form places you under NO OBLIGATION to purchase anything.
INFORMATION USE DISCLOSURE
We and the insurance companies that provide quotes use information, such as driving record, claims, and credit history, from consumer reporting agencies. Future reports may be used to update or renew your insurance. You may access and correct your personal information. LEUSCH Insurance Services' Privacy Policy explains how LEUSCH Insurance Services discloses and protects information. Each insurance company is responsible for maintaining their own privacy policies. We can provide a copy of these policies at your request.

Personal Information:
Your Name: Street Address: City/Township: State: Zip: Garaging Address: Currently insured with: How Long:
Current Policy Expiration Date:
Please Send Quote by E-Mail E-Mail Address:
Please have Representative Call me at: Days Evenings
Licensed Drivers & Vehicles:
Driver 1
Name: Date Licensed:
Birth Date: Male/Female: Marital Status:
Social Security #: Drivers License #:
Any ACCIDENTS or VIOLATIONS in the Past 5 Years? Yes No
(If YES, Please complete Accident & Violation Section Below)

Driver's License ever been SUSPENDED? Yes No
(If YES, Please provide Details in the Comments/Remarks Section below)

Vehicle Principally Driven by this Operator:

Year: Make: Model:
Vehicle Identification Number(VIN):
Body Type: Drive: Use: Work Miles(1 Way):
Annual Miles Driven:
Driver 2
Name: Date Licensed:
Birth Date: Male/Female: Marital Status:
Social Security #: Drivers License #:
Any ACCIDENTS or VIOLATIONS in the Past 5 Years? Yes No
(If YES, Please complete Accident & Violation Section Below)

Driver's License ever been SUSPENDED? Yes No
(If YES, Please provide Details in the Comments/Remarks Section below)

Vehicle Principally Driven by this Operator:

Year: Make: Model:
Body Type: Drive: Use: Work Miles(1 Way):
Annual Miles Driven:
Driver 3
Name: Date Licensed:
Birth Date: Male/Female: Marital Status:
Social Security #: Drivers License #:
ANY ACCIDENTS or VIOLATIONS in the Past 5 Years? Yes No
(If YES, Please complete Accident & Violation Section Below)

Driver's License ever been SUSPENDED? Yes No
(If YES, Please provide Details in the Comments/Remarks Section below)

Vehicle Principally Driven by this Operator:

Year: Make: Model:
Body Type: Drive: Use: Work Miles(1 Way):
Annual Miles Driven:
Driver 4
Name: Date Licensed:
Birth Date: Male/Female: Marital Status:
Social Security #: Drivers License #:
ANY ACCIDENTS or VIOLATIONS in the Past 5 Years? Yes No
(If YES, Please complete Accident & Violation Section Below)

Driver's License ever been SUSPENDED? Yes No
(If YES, Please provide Details in the Comments/Remarks Section below)

Vehicle Principally Driven by this Operator:

Year: Make: Model:
Body Type: Drive: Use: Work Miles(1 Way):
Annual Miles Driven:
Schedule of Accidents & Violations in the Last 5 Years:
Driver Name: Accident Violation Occurrence Date: Description:

Driver Name: Accident Violation Occurrence Date: Description:

Driver Name: Accident Violation Occurrence Date: Description:

Driver Name: Accident Violation Occurrence Date: Description:

Driver Name: Accident Violation Occurrence Date: Description:

Driver Name: Accident Violation Occurrence Date: Description:
Insurance Coverages Requested:
(These Coverages You Select are Automatically Applied to All Vehicles)

Bodily Injury Liability: Medical Payments:
Property Damage Liability: UM Property Damage Liab? Yes No Uninsured / Underinsured Motorist Liability:

(These Coverages You Select are Only Applied to the Vehicles that You Choose)

Vehicle 1:

Comprehensive: Collision:
Towing Rental Reimbursesment Lease/Loan Gap Anti-Theft Device
Anti-Lock Brakes Driver Side Air Bag Driver & Passenger Side Air Bag

Vehicle 2:
Comprehensive: Collision:
Towing Rental Reimbursesment Lease/Loan Gap Anti-Theft Device
Anti-Lock Brakes Driver Side Air Bag Driver & Passenger Side Air Bag
Vehicle 3: Comprehensive: Collision:
Towing Rental Reimbursesment Lease/Loan Gap Anti-Theft Device
Anti-Lock Brakes Driver Side Air Bag Driver & Passenger Side Air Bag

Vehicle 4:
Comprehensive: Collision:
Towing Rental Reimbursesment Lease/Loan Gap Anti-Theft Device
Anti-Lock Brakes Driver Side Air Bag Driver & Passenger Side Air Bag
Premium Discounts Available:
Good Student Discount (Drivers Ages 16 -24 with B Average or Better)
Names of Good Students:

Vehicles Driven To & From Work in Car Pools
Vehicles used in Car Pools:

Accident Prevention Course Completed (Drivers Age 60 or Older)
Names of Certified Drivers:

Auto/Home Discount
(Please complete a Homeowners Insurance Quote Request Form)

Comments & Remarks:


Copyrights 1996 , 1997,  2004 
Leusch Insurance Services Agency, Inc.
All Rights Reserved 
 
Coverage statements in this web site are general descriptions only. The full and exact contract is contained only in the policy. For costs and complete details of coverage, including applicable
exclusions and limitations, call or write our agency.

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Copyrights 1996 , 1997, 2004, 2008, 2009,2010, 2017 
Leusch Insurance Services Agency, Inc.
dba INSURANCE CONCEPTS
All Rights Reserved 
 
Coverage statements in this web site are general descriptions only. The full and exact contract is contained only in the policy. For costs and complete details of coverage, including applicable
exclusions and limitations, call or write our agency.
 
LEUSCH Insurance Services Agency, Inc. is licensed to do business in the following states:
Ohio, Pennsylvania, Michigan, Florida, New York, Texas, Illinois, and Iowa
 
* Privacy Policy *