Baldwin Insurance Agency, Inc.
This website offers services to current and future residents of Connecticut only.
30 Jordan Lane, Wethersfield CT 06109, Tel. (860) 563-0942   
 
Online Quotes-  Auto   Homeowners  Watercraft  Life   Contractors  Services-  Auto Claim  Homeowners Claim  Certificate of Insurance Request  Info Questionnaire  About Us-  Front Page   Contact Us  Other-  Portal Screen  News  Sports  Weather
Automobile Quote - 4 Drivers, 2 Vehicles
The quotes provided here are for CT only.
Fill out the form below to obtain an auto quote. You may add up to 4 drivers and 2 vehicles on this quote form. For additional vehicles or drivers, feel free to call us. For a quick quote on just 1 vehicle and 1 driver, see our Quick Quote form.
The quotes provided here are for CT only.
Vehicle(s) Registration Information Section
 The name and address to which the vehicle(s) is or will be registered:
Name:
Street:
City/State/Zip: / /
Home Phone: Work Phone:
Email Address:
Driver Information Section          Review Sections:
Driver Name :
As it appears on license		 Driver 1
Driver 2
Driver 3
Driver 4
State Licensed: Driver 1
Driver 2
Driver 3
Driver 4
Years of Driving Experience: Driver 1
Driver 2
Driver 3
Driver 4
Drivers License Number: Driver 1 
Driver 2 
Driver 3 
Driver 4 
Date of Birth: Driver 1
Driver 2
Driver 3
Driver 4
Social Security Number: Driver 1
Driver 2
Driver 3
Driver 4
Please check what applies to the driver: Driver 1 Defensive Driving Course Completed
Drivers Ed (males <21 years old only)
Driver 2 Defensive Driving Course Completed
Drivers Ed (males <21 years old only)
Driver 3 Defensive Driving Course Completed
Drivers Ed (males <21 years old only)
Driver 4 Defensive Driving Course Completed
Drivers Ed (males <21 years old only)
            Insurance Information
Do you have current insurance?: Driver 1
Yes/No
Driver 2
Yes/No
Driver 3
Yes/No
Driver 4
Yes/No
If yes, with what company?
(Please Be Specific):		 Driver 1
Driver 2
Driver 3
Driver 4
Please check the length of time you have been with your current insurance company : Driver 1
Less than 3 years
More than 3 years
Over 5 years
Driver 2
Less than 3 years
More than 3 years
Over 5 years
Driver 3
Less than 3 years
More than 3 years
Over 5 years
Driver 4
Less than 3 years
More than 3 years
Over 5 years
When does your current insurance expire?: Driver 1
"mmddyy"
Driver 2
"mmddyy"
Driver 3
"mmddyy"
Driver 4
"mmddyy"
Vehicle Information Section          Review Sections:
Year Vehicle 1
Vehicle 2
Make Vehicle 1
Vehicle 2
Model
(Please be as specific as possible. ie. Honda Accord LX, 4 door)		 Vehicle 1
Vehicle 2
City Primarily Garaged: Vehicle 1
Vehicle 2
Please check all that apply to the vehicle.    
Airbags Vehicle 1
Vehicle 2
Automatic Seatbelts Vehicle 1
Vehicle 2
Daytime Running Lights Vehicle 1
Vehicle 2
Antilock Braking System (ABS) Vehicle 1
Vehicle 2
Antitheft device (Alarm) Vehicle 1
Vehicle 2
Vehicle Recovery System (LoJack) Vehicle 1
Vehicle 2
Insurance Coverages Section          Review Sections:
Select Coverages from the Pull Down Lists Below. \/   

Bodily Injury to Others:

 Vehicle 1
Vehicle 2
Damage to someone else's property: Vehicle 1
Vehicle 2

Bodily Injury caused by Uninsured Motorist:

 Vehicle 1
Vehicle 2
Comprehensive Deductible: Vehicle 1
Vehicle 2
Collision Deductible: Vehicle 1
Vehicle 2
Medical Payments: Vehicle 1
Vehicle 2
Full Glass Coverage: Vehicle 1
Vehicle 2
Towing and Labor: Vehicle 1
Vehicle 2
Substitute Transportation: Vehicle 1
Vehicle 2
    End of Form                          Review Sections:
Select Response Method, then
click the Submit button below
Response Method
 I would like my quote sent to me via:
          Fax Number:
          Mailing Address: Street:
  City/State/Zip: / /
Homeowners Insurance Expiration Date:
If you are interested, we might be able to save you money on your Homeowners Insurance.		 mm/yyyy

How did you hear of us?     Other:

Comments:


         

We will send your quote promptly.
Thank you for considering Baldwin Insurance!


Copyright 1999-2001. DataTrails. All Rights Reserved.


Website Foundation by DataTrails