Gannon Agency - Online Auto Quote

Auto Insurance Quote
Please complete the following form and click the "Submit" button for a free quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Contact:	AM PM
Email Address:

Current Auto Insurance Information
*Company Name (Not agency):*
Policy Expiration Date:	Annual Premium: $
Term:	6 Months 1 Year Other:

Driver Information
(include all licensed drivers in your household)
Driver #1	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver #2	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver #3	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Courses Completed Last 3 yrs
		M F	Married Single	Drivers Ed: Y N Accident Prevention: Y N

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations* in the past 3 years*
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph
			$	mph

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver	Date	Description	Cost	Fines	Injuries	At Fault
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes

Vehicle Information
(include all cars you or your family members own or lease)
Auto #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Operator Number		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way			Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Auto #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Operator Number		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way			Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Auto #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Operator Number		Annual Milage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way			Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Liability & First Party Benefit Limits (For ALL Vehicles)
Choose either Bodily Injury and Property Damage	or Single Limit
Bodily Injury: Property Damage:	Single Limit:
Uninsured & Underinsured Motorist Split Limits Coverage: or Uninsured & Underinsured Motorist Combined Coverage:
Uninsured & Underinsured Stacked: or Uninsured & Underinsured Unstacked:	Yes Yes
Extraordinary Medical Benefits:
First Party Medical Benefits:
Accidental Death Benefits:
Rental Reimbursement:
Wage Loss Benefits:
Towing Coverage:
Funeral Benefits:
Tort Option:

Deductibles and Misc.
Auto #	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes

Package Discount
My Homeowners Ins Policy Expires:	/ /

Additional Comments

Please provide any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

2383 Pasqualone Blvd., Village Shopping Center, Bensalem, PA 19020
e-mail steve@gannonagency.com or michele@gannonagency.com
Tel (215)891-9990 Fax (215)891-9995

Disclaimer: The Gannon Insurance Agency, Inc. is licensed to conduct business in Pennsylvania. The information on this site is a solicitation to conduct business only in the aforementioned state of authority.