Auto Insurance Form

570.226.4571 amskier@amskier.com

Please complete as much of this form as possible.
Full Name*
A value is required.
Birth Date*
A value is required.Invalid format.
Social Security Number*
Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Spouse/Partner Full Name
Birth Date
Invalid format.
Social Security Number
Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Email Address*
Additional Email Address
Home Phone*
A value is required.
Work Phone
Resident Address*
A value is required.

Any auto claims in the last 5 yrs



If yes, date & description

Driver Information
Drivers 1 information
state issued, license number
Driver 2 information
state issued, license number
Driver 3 information
state issued, license number
Driver 4 information
state issued, license number

Vehicle 1 Information (Required)
Who is the primary driver of this auto?
Do you own or lease this auto?



If leased, please enter lessor contact information
(name, address, city, state, zip, phone)

Year*
A value is required.
Make*
A value is required.
Model*
A value is required.
Vin Number*
A value is required.
Comprehensive Deductibles





Collision Deductibles





Towing and Labor




Rental Car





Vehicle 2 Information (If Applicable)
Who is the primary driver of this auto?
Do you own or lease this auto?



If leased, please enter lessor contact information
(name, address, city, state, zip, phone)

Year
Make
Model
Vin Number

If the following information is not known, please leave blank.
Enter Liability information in the next section.
Comprehensive Deductibles





Collision Deductibles





Towing and Labor




Rental Car





Vehicle 3 Information (If Applicable)
Who is the primary driver of this auto?
Do you own or lease this auto?



If leased, please enter lessor contact information
(name, address, city, state, zip, phone)

Year
Make
Model
Vin Number

If the following information is not known, please leave blank.
Enter Liability information in the next section.
Comprehensive Deductibles





Collision Deductibles





Towing and Labor




Rental Car





Liability Information
If the following information is not known, please leave blank.
Liability Limits







How did you hear about us?
Provide detail in the field below







Comments/Notes