Vermont Auto Insurance Quotes - Kinney Pike - Protecting people and businesses in Vermont & New Hampshire for over 100 years

Auto Insurance Quote

Thank you for your interest in finding out how Kinney Pike can help you meet your auto insurance needs. Please complete this brief questionnaire and a representative will get back in touch with you right away.

All questions must be answered before we can provide you a quote.

To Help Us Get Started
How did you hear about us?
If Other, please specify

Do you belong to any organizations?

Insured Information
Insured Name

Address

City

State		Zip
If less than 3 years, previous address
Previous Address

City

State		Zip

Phone

Date of Birth

Social Security Number

Email
Current Insurance
Do you presently have Auto Insurance?

Company Name

Renewal Date

Annual Premium

Have you been cancelled or non-renewed in the past 3 years?
If yes, please provide details
Have you had any SR-22 filings?

If Yes, please provide State		and Driver's License #
Coverages
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Towing & Labor









Licensed Drivers 1. (Primary Driver)
Name on License

License State		License Number

Date of Birth

Gender

Marital Status

Relationship to Applicant

Occupation

If applicable, is driver a full-time student with a B average or better?

Did driver complete Drivers’ Ed course?

Tickets and Accidents (last 5 years)
2. (Secondary Driver)
Name on License

License State		License Number

Date of Birth

Gender

Marital Status

Relation to Applicant

Occupation

If applicable, is driver a full-time student with a B average or better?

Did driver complete Drivers’ Ed course?

Tickets and Accidents (last 5 years)
Other Drivers
Please provide the following information of any other residents in your household licensed to drive.
1. Name

Date of Birth		License Number

2. Name

Date of Birth		License Number

3. Name

Date of Birth		License Number

Vehicles(s) Information 1.
Year

Make

Model

VIN

License State

Annual Mileage

# of Doors

4-Wheel Drive
Alarm System
Air Bags
Anti-Lock Brakes
Auto-Seatbelts

Vehicle Use

Miles one way to place of work
If motorcycle,
# CC's
Value
Accessory Value
2.
Year

Make

Model

VIN

License State

Annual Mileage

# of Doors

4-Wheel Drive
Alarm System
Air Bags
Anti-Lock Brakes
Auto-Seatbelts

Vehicle Use

Miles one way to place of work
If motorcycle,
# CC's
Value
Accessory Value

Some carriers require us to run credit reports. Do we have your permission to run a credit report, if required?
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

* If after clicking "Submit Request" the form does not get submitted, review the form and enter any missing information.