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Automobile Quote Form
Note: Offer only pertains to residents of Maine or anyone relocating to Maine

Please fill out the following form, and then click on the "Submit Quote" button. Your request will be processed and you will receive a quote soon.
Applicant Info

Name:  
Spouse's Name:  
Your email address:  
Mailing Address:  
City:  
State:  
Zip Code:  
Phone #:  
What is your Date of birth?  
How many years have you had a license?  
What is your license #?  
What is your Social Security #?  
What is your spouse's Date of birth?  
How many years has your spouse had a license?  
What is your spouse's license #?  

Are all of the residents of your house non-smokers? yes no

If there are any other licensed drivers in your household,
please list their names, dates of birth and drivers license numbers here.
Do all drivers have Maine licenses? yes no
Have any drivers taken Drivers Training classes? yes no
Have any drivers been placed on the Honor Roll,
Dean's List, etc., at a school?
(some companies offer discounts for this.) 		yes no
Vehicle 1
Year:
Make:
Model:
2 Door 4 Door
2 Wheel Drive 4 Wheel Drive
What is your commute distance(one-way, in miles)?
Vehicle has Anti-lock Brakes? yes no
Vehicle has Air Bag? yes no
Vehicle has Automatic belts? yes no


Vehicle 2
Year:
Make:
Model:
2 Door 4 Door
2 Wheel Drive 4 Wheel Drive
What is your commute distance(one-way, in miles)?
Vehicle has Anti-lock Brakes? yes no
Vehicle has Air Bag? yes no
Vehicle has Automatic belts? yes no


Vehicle 3
Year:
Make:
Model:
2 Door 4 Door
2 Wheel Drive 4 Wheel Drive
What is your commute distance(one-way, in miles)?
Vehicle has Anti-lock Brakes? yes no
Vehicle has Air Bag? yes no
Vehicle has Automatic belts? yes no


If there is any additional equipment on the vehicles
(snowplow, cellular phone, etc.),
please value it here:
Do you carry insurance now? yes no
If so, what is the providers name?
What is the expiration date?
What is the premium?
Please enter desired coverages for each category:
Bodily Injury: Max per person:
Max per accident:
Uninsured Motorist: Max per person:
Max per accident:
Property Damage:
Medical Payments:
Comprehensive Coverage:
Veh. 1:
Veh. 2:
Veh. 3:
Collision Coverage:
Veh. 1:
Veh. 2:
Veh. 3:
Do you want coverage for towing? yes no
Do you want coverage for rental? yes no
Are all vehicles registered in Maine? yes no
Are all vehicles titled in your name? yes no
If not, in whose name are they titled?


Are there any other vehicles furnished for your regular use
(company cars, etc.)? yes no

If yes, please explain:


What is your occupation?
What is your spouse's occupation?

Is there any business purpose for the vehicles
(including Avon, Tupperware, etc.)? yes no

If so, explain here:


Please list any accidents that have occurred within 3 years:


Please list any traffic violations that have occurred within 3 years:



Are you required to file an SR22? yes no
I would like to receive my quote by: 
What is the best time to contact you by phone?
Anything else we may need to know?
© GHM Agency 2004

Disclaimer: Please be advised that no insurance can be purchased, bound, or put into effect over the GHM Agency website. To start a policy or make changes to an existing policy, you must first speak with a GHM agent who will assist you accordingly. Thank You.