We would like to provide you with a
free, no-obligation Automobile Insurance Quote. Please provide as much
information possible for the most accurate quote. This information will
be kept confidential and will be used for quote purposes only.
Please note this is not an
application but a request for a quote and is non binding until money is
received and we have accepted your application.
PERSONAL & DRIVER INFORMATION
Full Name
Marital Status:
Date of Birth:
use
mm/dd/yyyy form
Drivers License #
Social Security #
Address:
City:
State:
Zip:
Phone:
Violations past 3 years
SPOUSE INFO:
Spouse's Name
Date of Birth:
use
mm/dd/yyyy form
Drivers License #
Social Security #
Violations past 3 years
OTHER DRIVER
INFO:
Note: Info below for
any household members over the age of 14 if they don’t drive we
can exclude them.
Other Driver's Name
Date of Birth:
use mm/dd/yyyy form
Drivers License #
Social Security #
Violations past 3 years
VEHICLE INFORMATION
CAR 1
Vehicle ID Number (VIN):
Year:
Make:
Model:
Comp Deductible
Collision Deductible
Bodily Injury
Property Damage
Under Insured
Uninsured
Med Pay
Commute Miles One Way to Work/School:
Annual Mileage:
Pleasure Mileage:
CAR 2
Vehicle ID Number (VIN):
Year:
Make:
Model:
Comp Deductible
Collision Deductible
Bodily Injury
Property Damage
Under Insured
Uninsured
Med Pay
Commute Miles One Way to Work/School:
Annual Mileage:
Pleasure Mileage:
CAR 3
Vehicle ID Number (VIN):
Year:
Make:
Model:
Comp Deductible
Collision Deductible
Bodily Injury
Property Damage
Under Insured
Uninsured
Med Pay
Commute Miles One Way to Work/School:
Annual Mileage:
Pleasure Mileage:
CURRENT AUTO INSURANCE INFORMATION
Company Name:
64
How Long with Company?
Renewal Date:
Homeowner Status:
Premium:
Your Email Info:
Email Address:
ADDITIONAL COMMENTS
Please give any additional comments you feel
are appropriate for this quote. If you have additional information
where there was not enough room above, such as Additional
Drivers, Vehicles, Driver Histories, any DUI Convictions,
Revocations, or License Suspensions, etc..., please enter them
here:
Personal & Professional
Service
is what you will find at
Barkema
Insurance Agency..... Let us serve you today.
Mailing Address:
PO BOX 183
Murray, IA 50174 Physical Address:
109 1st St.
Murray, IA
Directions to our
Office:
From Osceola:
West on Hwy 34
9 miles From Creston East on Hwy 34
25 miles To 135th Ave (Murray cemetery) Turn
right (north) & go ¾ mile. When the road
curves to right, go left (1st ST).
We are about 1 ½ blocks down on the Left (north) side of
the street.
109 1ST St
