Automotive Insurance Quote – Richards Insurance Agency

You may use the form below to request a free automotive insurance quote online. Alternatively, you may contact us if you have any questions or would like to request a quote by phone or in person!

*First Name:

*Last Name:

*Date of Birth: (mm/dd/yyyy)

SSN:

Social Security Number Information
Why are we asking for your social security number?
Many insurance companies include an insurance credit score, based on formulas weighting different credit factors from your credit report. Supplying your Social Security Number will help assure that the right credit record is used and that any premium estimate is accurate.

License Number:

License Number
Why are we asking for your license number?
Supplying your License Number will help assure that the right credit record is used and that any premium estimate is accurate.

*Phone:

*Physical Address:

PO Box Address:

*City:

*State:

*ZIP Code:

Fax:

*Are you insured now?

Reason for changing (if applicable)?:

*Any accidents within 5 years?

*Any tickets within 5 years?

*Vehicle Information

*Year:

*Make:

*Model:

*Vin No.:

Second Vehicle Information (if applicable)

Year:

Make:

Model:

Vin No.:

Third Vehicle Information (if applicable)

Year:

Make:

Model:

Vin No.:

Coverages (Please call for higher limits)

*Bodily Injury:

*Property Damage:

*P.I.P:

*Comprehensive:

*Collision:

*Full Glass: