General Information
Name
Email
Address
City
State
Zip
Previous Address if less than 2 years
Phone
Household Members (including non-drivers)
Number of Household Members:  1     2     3     4     5      6
Household Member 1
Name
Date of Birth
Drivers License Number
Social Security Number
Vehicles
Number of Vehicles:  1     2     3     4     5      6      7
Vehicle 1
Year
Make
Model
VIN
Driven By
Use
Coverages
Number of Coverages:  1     2     3     4     5      6      7
Coverage 1
Liability Limits
Comp Deductible
Coll Deductible
Towing
Rental Reimbursement
Disclaimer Notice: The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, not does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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Whitaker-LaChance Agency
2176 East Centre Ave.
PO Box 1806
Portage, MI 49081-1806
Toll Free: 800.968.1959
Phone: 269.324.7700
Fax: 269.324.5660
     


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