IS GARAGING ADDRESS AND MAILING ADDRESS THE SAME?
IF NO, PLEASE COMPLETE THE GARAGING ADDRESS BELOW:
(IF OTHER, EXPLAIN IN REMARK SECTION)
AUTO LIABILTY LIMIT:
UNINSURED MOTORIST LIMIT:
MEDICAL PAYMENT LIMIT?
TRUCK AND OR TRAILER PHYSICAL DAMAGE?
IF YES, DEDUCTIBLES:
This is a request for a price indication. This application does not bind the applicant nor the Company(s) to complete the
insurance, but it is agreed that the information contained herein shall be the basis
of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
By clicking submit this form, I am providing express written consent to being contacted by one or more agents/brokers of
Safepro Insurance Services to discuss my interest, including offers of insurance, at
the phone number and/or email address I have provided to you in submitting this form
and/or additional information obtained. I consent by electronic signature to being contacted
by telephone (via call and/or text) for marketing/telemarketing purposes at the phone
number I provided in this form, even if my phone number is listed on a Do Not Call Registry,
and I agree that such contact may be made using an automatic telephone dialing system
and/or an artificial or prerecorded voice (standard call, text message, and data rates
apply). I can revoke my consent at any time. I also understand that my agreement to be
contacted is not a condition of purchasing any property, goods or services, and that
I may call 1-888-411-7679 to speak with someone about obtaining an insurance quote.
the arbitration provision and the E-SIGN Consent.