Burns Insurance

Driver

Marital Status

Years Licensed

Gender

Drives Which Car?

License #

Burns Insurance Agency, LLC
500 South Central Avenue
Marshfield, WI 54449
715-387-0002

Automobile Insurance Quote Request
Please complete the form below and click on the button labeled 'Submit Quote Request'. Since our Internet quote forms do not ask for confidential information such as Social Security Number, an agent may contact you to obtain more information when putting together your quote.

If you have any questions or would like an immediate quote, please contact one of agents at insure@burns-insurance.com.

Please note that any fields followed by ** are required.

PERSONAL INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip Code:

CONTACT INFORMATION

Phone:

Fax:

Email:

CURRENT INSURANCE

Current Company:

Current Premium:

How many years have you had coverage with your current company?

VEHICLE INFORMATION

Vehicle	Year	Make	Model	VIN #
1**
2
3

VEHICLE USAGE (Please fill in for each vehicle listed above)

Vehicle

1**

DRIVER INFORMATION

Driver	DOB	Employer	Occupation
1**
2
3
4

Has any driver received a traffic ticket, been involved in an accident, had any license suspensions, or filed an insurance claim?:

If yes, please explain:

INSURANCE REQUIRED

Split Limit Liability, Body Injury Liability, per person/per occurence:

If other, please specify:

Property Damage Liability:

If other, please specify:

Uninsured Motorist, per person/per occurence:

If other, please specify:

Underinsured Motorist:

If other, please specify:

Medical Payments:

If other, please specify:

Comprehensive Deductible:

Vehicle 1:

Vehicle 2:

Vehicle 3:

Collision Deductible:

Vehicle 1:

Vehicle 2:

Vehicle 3:

Towing:

Rental Reimbursement:

Additional Information:

RETURN OPTIONS

Please email the quote to me.

Please fax the quote to me.

Please mail the quote to me.

Please call me.