Auto Insurance Quote Request

Products and services offered by the Eck Agency may not be available in all states. This information shall not constitute an offer in any state in which a product or company is not properly registered or licensed. The Eck Agency generally offers and sells its products and services only in the states of Kansas and  Oklahoma. This information shall not constitute an offer in any foreign country.  All quotes are subject to underwriting and may not be available in all states.

Vehicle Owner information (as shown on title):

State of Residence
Name
Address
City/Zip   
Contact Numbers Home Phone:   Work Phone:    Cell Phone:   
 E-mail
Contact at:    Home Phone   Work  Phone    Cell Phone   E-mail
Current Employer
Credit History Why Credit is Important

   Good     Not so Good   Reason if not Good Credit :

I grant permission for Insurance companies to check my credit See Privacy Notice

I do not grant permission (we cannot supply a quote without your permission to check credit)
Marital Status Married Not Married
Own home? Yes     No
Number of licensed drivers  in Household

Coverage Desired:

Coverage Liability Limits (in thousands)
Bodily Injury25/50   50/100   100/300   250/500
  
Property Damage10    25    50    100   250
  
Uninsured Motorist25/50   50/100   100/300   250/500
  
CollisionYes    No
Collision Deductible100     250     500    1000
  
ComprehensiveYes    No
Comprehensive Deductible50      100      250     500
Vehicle and Driver Information
Vehicle 1
Year
Make
Model
VIN #
# of Cylinders     # of  Doors
 Use
Family 
To/From Work
Commercial
Coverage Type Full Coverage  Liability Only 
Driver 1
Full Name
Date of Birth
Sex Male Female
Driver License #   
State
Social Security #
Last 3 years Tickets   Accidents
Describe any tickets or accidents
If no other vehicles or drivers go to end of form
Vehicle 2
Year
Make
Model
VIN #
# of Cylinders     # of  Doors
 Use
Family 
To/From Work
Commercial
Coverage Type Full Coverage  Liability Only 
Driver 2
Full Name
Date of Birth
Sex Male Female
Driver License #   
State
Social Security #
Last 3 years Tickets   Accidents
Describe any tickets or accidents
If no other vehicles or drivers go to end of form
Vehicle 3
Year
Make
Model
VIN#
# of Cylinders     # of  Doors
 Use
Family 
To/From Work
Commercial
Coverage Type Full Coverage  Liability Only 
Driver 3
Full Name
Date of Birth
Sex Male Female
Driver License #   
State
Social Security #
Last 3 years Tickets   Accidents
Describe any tickets or accidents
If no other vehicles or drivers go to end of form
Vehicle 4
Year
Make
Model
VIN#
# of Cylinders     # of  Doors
 Use
Family 
To/From Work
Commercial
Coverage Type Full Coverage  Liability Only 
Driver 4
Full Name
Date of Birth
Sex Male Female
Driver License #   
State
Social Security #
Last 3 years Tickets   Accidents
Describe any tickets or accidents
IF more than 4 drivers and/or vehicles please call 800-444-4911

End of Form

 

Copyright © 2000 Eck Agency, Inc All rights reserved.
Revised: April 29, 2008

 

 

 

 

 

Why Credit is Important

Many insurance companies now require a credit check to write or even quote both auto and homeowners insurance.  The reason is that people with good credit have many fewer claims than those who don't.  One major company experienced non-catastrophe losses that were 5 times higher from its insureds who had a low credit score vs. their insureds who had exceptional credit.  We do need your permission to check your credit score.  Back to form