Auto Insurance Quote Request

Please complete the form below to receive an auto insurance quote from Phillips Stafford Insurance Group. You can complete as much or as little of the information as you would like. We can always give you a call to gather the missing information. The more complete information we receive the faster we can prepare a quote for you. We make it our goal to get back to you within 1 business day.

1General Info

2Drivers

3Vehicles

4Policy Coverages

5Underwriting Questions

6Submit

Name*
First Last
Phone*
Email*
Preferred Contact Method*
- Phone
- Email
Would you like to package your auto insurance?
Check all that apply
- Package with Home
- Package with Toy (motorcycle, ATV , Snowmobile, RV, etc)
- Package with Umbrella
Have you been working with one of our agents?
Please enter their name here.
Please chose your preference*
- Please call me to gather my personal information
- I would like to fill out my personal information here for a faster quote
Please include as little or as much additional information as you would like. We will contact you to gather any additional information we need.
Address
Street Address Address Line 2 City State ZIP Code

Driver Information
How many total drivers will be on the policy?
Driver 1
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 2
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 3
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 4
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 5
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 6
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY

Vehicle Section
How many vehicles do you need to insure?
Vehicle 1
VIN
---OR---
Year
Make
Model
Vehicle Use
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 2
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 3
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 4
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 5
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 6
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 7
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 8
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement

Auto Insurance Quote Request

Driver Information

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Vehicle Section

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Policy Level Coverages

Underwriting Questions

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