John Sieh Agency Insurance

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	For a request of auto insurance rates, please complete this form in its entirety. Should you submit the form and receive a message that a required field was not completed, use the back button on your browser to return to this form. The information submitted via this form is received directly to John Sieh Agency and is confidential. Fill in this form as complete as possible to ensure an accurate rate. If you are unsure of the correct answer to any of the fields, other than the required fields, skip them, but note in the comments section what you were unsure about.

Auto Insurance Quote

Name:
Physical Address:
City		State:	Zip:

Mailing Address:
City:		State:	Zip:
Home Phone:		Work Phone:
Email:

Coverage
Have you had continuous coverage for at least 12 months? Yes No
If not, please describe:

Present Auto Insurance Company:
Renewal Date:
Own Home?	Yes No

Car #1 Information
Year:
Make:
Model:
2 Dr/4 Dr
Miles to Work: (one way)
Annual Mileage:
Type of Anti-Theft Device on Vehicle:
Vin #

Car #2 Information
Year:
Make:
Model:
2 Dr/4 Dr
Miles to Work: (one way)
Annual Mileage:
Type of Anti-Theft Device on Vehicle:
Vin #

Car #3 Information
Year:
Make:
Model:
2 Dr/4 Dr
Miles to Work: (one way)
Annual Mileage:
Type of Anti-Theft Device on Vehicle:
Vin #

Driver #1 Information
Driver Name:
Occupation:
Business:
Length at Current Job:
Highest Level of Education:
Date of Birth:
Drivers License Number:
Social Security Number: Many of the companies we represent require this information prior to quoting.
Gender	Male Female
Marital Status:
Moving Violations in the Last 3 Years? 0 1 2 3 4
Please provide the date and a brief description of each violation.

Accidents in the Last 3 Years? 0 1 2 3
Please provide the date and a brief description of each accident.


Driver #2 Information
Driver Name:
Occupation:
Business:
Length at Current Job:
Highest Level of Education:
Date of Birth:
Drivers License Number:
Social Security Number: Many of the companies we represent require this information prior to quoting.
Gender	Male Female
Marital Status:
Moving Violations in the Last 3 Years? 0 1 2 3 4
Please provide the date and a brief description of each violation.

Accidents in the Last 3 Years? 0 1 2 3
Please provide the date and a brief description of each accident.


Driver #3 Information
Driver Name:
Occupation:
Business:
Length at Current Job:
Highest Level of Education:
Date of Birth:
Drivers License Number:
Social Security Number: Many of the companies we represent require this information prior to quoting.
Gender	Male Female
Marital Status:
Moving Violations in the Last 3 Years? 0 1 2 3 4
Please provide the date and a brief description of each violation.

Accidents in the Last 3 Years? 0 1 2 3
Please provide the date and a brief description of each accident.


Liability Limit for All Cars
Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury:
Property Damage:
Single Limit:
Levels of Current Uninsured Motorist Coverage:

Car #1
Deductible Comprehensive: 100 250 500
Deductible Collision: 100 250 500
Tow	Yes No
Loss of Use:	Yes No

Car #2
Deductible Comprehensive: 100 250 500
Deductible Collision: 100 250 500
Tow	Yes No
Loss of Use:	Yes No

Car #3
Deductible Comprehensive: 100 250 500
Deductible Collision: 100 250 500
Tow	Yes No
Loss of Use:	Yes No

Comments
If you have any questions or any comments, please use the space below.

ABERDEEN OFFICE

IPSWICH OFFICE

702 S. Main Street • Aberdeen, SD 57401
605-229-1760 • 1-800-658-3653

504 4th Street • Ipswich, SD 57451
605-426-6330 • 1-800-532-0457