Auto Insurance Quote Form
Pennsylvania Only

To receive a quote, please fill out the form below.....


Name:     Social Security #: 
Address:
City:   State:    Zipcode: 
Phone Numbers:
E-Mail Address:
Do you belong to any of these groups?



Current Carrier Information and Expiration date of policy?
Your Current Insurance Company Name:  Policy Expiration date: 



Tort Option:   "Limited" Tort limits your ability to sue, "Full" Tort does not.


Liability Limits
Bodily Injury Limit / or Single Limit per Accident Property Damage Limit


Un and Underinsured Motorist Coverage
Limit Option: Stacked / Non-Stacked


Pennsylvania First Party Benefits
Please select either Selected First Party Benefits or Combined Benefits

S E L E C T E D   F I R S T   P A R T Y   B E N E F I T S

Medical Expenses Work Loss Benefits Funeral Expenses Accidental Death Benefits

OR

C O M B I N E D   F I R S T   P A R T Y   B E N E F I T S

Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit)
   Do you need Work Loss Benefits? 

Extraordinary Medical Benefits  (Medical Expenses from $100,001 to....)
Benefit Limit: 


VEHICLE INFORMATION
Vehicle 1
Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded
Collision
Ded
Yes /  No
RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 2
Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded
Collision
Ded
Yes /  No
RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 3
Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded
Collision
Ded
Yes /  No
RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 4
Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded
Collision
Ded
Yes /  No
RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 5
Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded
Collision
Ded
Yes /  No
RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES



DRIVER INFORMATION
Driver Name Birth Years Licensed Sex Marital Status License # Occupation * Defensive Driving Course or Driver Training Course
In the last 3 years
If student, QPA
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
* Occupation is now needed: Insurance companies are now asking for the driver's occupation because they are now using it in the rating structure



PERCENTAGE OF USE
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5
Driver # 1: % % % % %
Driver # 2: % % % % %
Driver # 3: % % % % %
Driver # 4: % % % % %
Driver # 5: % % % % %



ACCIDENTS & VIOLATIONS
Does any driver have any accidents or violations?    Yes       No
If "YES", Please list ALL accidents and violations within last 3 years......
 
DATE DRIVER NAME TYPE OF OCCURRENCE



GENERAL INFORMATION
  • Where do you live? 
  • Any unrepaired damage to any vehicle of 200 or more? 
  • How many years have you been with your existing insurance company? 
  • Are you a member of AAA?  Yes  No


  • (After you Submit) For better auto rates, please quote my HOMEOWNERS/RENTERS INSURANCE

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    M c G R A T H   I N S U R A N C E   G R O U P

    4170 William Penn Highway, Murrysville, PA. 15668-1890
    (724) 327-8474           Fax: (724) 327-7911
    Toll Free: 1-800-977-2999      Fax: 1-888-800-0034