Inter-Agency Insurance Service, Inc.

We offer a variety of coverages based on your specific needs. If you have a good driving record we have very competitive auto rates. Fill out the preliminary form below and one of our agents will contact you.

Name

Address

City

State Zip

Work Phone

Home
Phone

E-mail

Present Auto Insurance Co

Date Auto Insurance Expires

Do you own a home? Yes No

How long at present address?

Car Year Make Model 2dr or 4dr Miles to Work
(one way) Annual Mileage

#1

#2

#3

Driver Name Driver Name Driver Name

Date of Birth

Sex

Marital Status

Occupation

Number of Tickets in Last 3 Years

Number of Accidents in Last 3 Years

Percent of Use

Car #1

Car #2

Car #3

LIABILITY LIMIT FOR ALL CARS

Bodily Injury Property
Damage

Single Limit
choose one

25,000/50,000 25,000

60,000

50,000/100,000 50,000

100,000

100,000/300,000 100,000

300,000

250,000/500,000 500,000

500,000

Choose either Bodily Injury & Property Damage OR Single Limit

Car Deductible Comprehensive Deductible Collision Tow Loss of Use

#1 100 250 500 250 500 1000 Yes Yes

#2 100 250 500 250 500 1000 Yes Yes

#3 100 250 500 250 500 1000 Yes Yes