Our Auto & Home Insurance Carriers
• American Modern
• Chubb
• Colorado Casualty
• Foremost Insurance Group
• Metlife
• Occidental
• Progressive
• RLI
• Safeco
• Sentry Insurance
• The Hartford
• Travelers

Auto Insurance Application

Pritchard Group Insurance makes shopping for auto insurance easy. Please fill out as much information as you can at this time to give us a head start on finding the perfect insurance coverage for your needs. Please expect a response within 24-48 hours so that we may research all money-saving opportunities. By filling out this form you are giving permission to Pritchard Group Insurance to contact you by phone to verify or clarify informatiopn provided.

Note: AZ Minimum Liability Limits are:
• Bodily Injury per person: $15,000
• Per Accident $30,000
• Property Damage $10,000

Name of Primary Insured:	*
Street Address:	*
City / State / ZIP:	*
Home Phone (area code):	*
Business Phone:	*
Cell Phone:
Number of Drivers to be Insured:	*
Number of Vehicles to be Insured:	*
Email:	*
Current Insurance Carrier:
Policy Number:
How Many Years have you Owned Policy:
Renewal Date:
Current Premium $:
AARP / AAA Member #:

Driver #1 Full Name:
Marital Status:
SS#:
Month/Day of Birth:
Year of Birth:
Driver's License #:
State:
Miles to Work:
Tickets in past 5 years:
Tickets in past year:
Bodily Injury Liability:
Property Damage:
Medical:
Uninsured Motorist:
Underinsured Motorist:
Combined Single Limit:
Excess Liability Needed:
Comprehensive Deductible:
Collision Deductible:
Car Rental Deductible:
Towing Deductible:

Vehicle #1 Make:
Model:
Year:
VIN#:
ABS Brakes:
Air Bags:
Anti-Theft:
Purchased:
Date:
Cost New: $
Special Equipment:
Lein Holder:

Driver #2 Full Name:
Marital Status:
SS#:
Month/Day of Birth:
Year of Birth:
Driver's License #:
State:
Miles to Work:
Tickets in past 5 years:
Tickets in past year:
Bodily Injury Liability:
Property Damage:
Medical:
Uninsured Motorist:
Underinsured Motorist:
Combined Single Limit:
Excess Liability Needed:
Comprehensive Deductible:
Collision Deductible:
Car Rental Deductible:
Towing Deductible:

Vehicle #2 Make:
Model:
Year:
VIN#:
ABS Brakes:
Air Bags:
Anti-Theft:
Purchased:
Date:
Cost New: $
Special Equipment:
Lein Holder:

Driver #3 Full Name:
Marital Status:
SS#:
Month/Day of Birth:
Year of Birth:
Driver's License #:
State:
Miles to Work:
Tickets in past 5 years:
Tickets in past year:
Bodily Injury Liability:
Property Damage:
Medical:
Uninsured Motorist:
Underinsured Motorist:
Combined Single Limit:
Excess Liability Needed:
Comprehensive Deductible:
Collision Deductible:
Car Rental Deductible:
Towing Deductible:

Vehicle #3 Make:
Model:
Year:
VIN#:
ABS Brakes:
Air Bags:
Anti-Theft:
Purchased:
Date:
Cost New: $
Special Equipment:
Lein Holder:

	Please send me a quote based on the information I have provided in this on-line application form.