Peoples Insurance Agency, INC 280 Hardie Ave SW Suite 1, Renton, WA 98057 Phone 425-271-7980 fax 425-738-9795
 
 
 
 
 

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GET A QUOTE
*First Name:
Middle Initial:
*Last Name:
*Day Phone:    –   ext.
*State Drivers License #
Social Security Number (optional)
*Address:
*City:
*State:  
*Zip code:
Cell Phone:    –   ext.
*Email:
*Gender:
*Date of Birth (mm/dd/yyyy): / /
*Marital Status:
Occupation:
*Are you a Home Owner? Yes     No
How many years have you been licensed? /yrs
Current Insurance Company (if applicable):
How long have you been with your current provider: /yrs /mo

 

How did you hear about us?
*How did you hear about us?

 

Tell Us About Your Spouse (if applicable)
*Spouse's First Name:
Spouse's Last Name:
*Gender:
*Date of Birth (mm/dd/yyyy): / /
Occupation:
*How many years have your spouse been licensed? /yrs
Current Insurance Company (if applicable):
How long has your spouse been with his/her current provider: /yrs /mo

 

Additional Drivers
If you are insuring drivers other than yourself including your spouse, please fill out their information below. If you need to insure more than 4 drivers, please make note in the comments area at the bottom of the form.
First Name Date Of Birth Licensed
 /  /   /yrs
 /  /  /yrs
 /  /  /yrs
 /  /  /yrs

 

Driving Violations
*How Many Violations or Accidents have you had in the last 3 years?
Please specify violations for the drivers above. If there are more than 8 violations, please make note in the comments area at the bottom of the form.
Driver's Name Violation Date of Violation
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 

 

Need A SR-22?
If you need an SR-22 filing, please indicate the State here.

 

Tell Us About Your Vehicles
*If you have more than 3 vehicles, please make note in the comments area at the bottom of the form.

Vehicle One
*Year:
*Make:
*Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Two
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Three
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

 

Coverage Information
*Liability:
*Uninsured Motorist:
*Personal Injury Protection:

 

Additional Information
Please provide any additional driver, vehicle or violation information
that will help us process your Insurance Quote:
 

 

Contact Options
*How should we reach you?
Day Phone   Cell Phone

* Required Fields

Thank you for your quote request. Our agents will get back to you as soon as possible with your quote.
 
 

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