Our Auto & Home Insurance Carriers

• American Modern
• Bristol West
• Chubb
• Colorado Casualty
• Foremost Insurance Group
• Metlife
• National General
• Occidental
• Progressive
• RLI
• Safeco
• Sentry Insurance
• The Hartford
• Travelers

Auto Insurance Application

Pritchard Group Insurance makes searching for auto insurance easy. Please complete as much information as you can at this time to assist in finding the perfect insurance coverage for your needs. You can expect a response within 24-48 hours so we may research all various opportunities. By filling out this form you are giving permission to Pritchard Group Inc. to contact you by phone to both clarify and verify any information 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 #:

Marital Status:

Driver #1 Full Name:
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:
Lien Holder:

Marital Status:

Driver #2 Full Name:
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:
Lien Holder:

Marital Status:

Driver #3 Full Name:
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:
Lien Holder:

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