1233 N Mayfair Rd # 104, Milwaukee, WI
Phone: (414) 453-6181 – Fax: (414) 453-0080 –
agents@macgillisandcompany.com
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Contact Information
Name:
Phone Number:
Email:
Preferred Method of Contact:
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Email
Phone
Preferred Time of Day to Call:
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Morning
Evenings
Weekends
Question/Comment:
Auto Insurance Quote Information
Bodily Injury Liability:
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50/100
100/300
250/500
Property Damage:
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50,000
100,000
250,000
Medical:
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Reject
10,000
Uninsured Motorist:
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100/300
250/500
Underinsured Motorist:
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100/300
250/500
Comprehensive Deductible:
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100
250
500
1000
Collision Deductible:
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100
250
500
1000
Towing Reimbursement:
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50
75
100
Rental Reimbursement:
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20/600
30/900
50/1500
Year
Make
Model
Vehicle Identification Number
Vehicle 1:
Vehicle 2:
Vehicle 3:
Drivers in Household
Name
Date of Birth
Drivers License Number
Driver 1:
Driver 2:
Driver 3:
Any driver in school with 3.0 or better GPA:
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Yes
No
Any tickets or accidents per driver:
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Yes
No
Speeding?
Accidents?
Other?
Driver 1:
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Yes
No
Select...
Yes
No
Select...
Yes
No
Driver 2:
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Yes
No
Select...
Yes
No
Select...
Yes
No
Driver 3:
Select...
Yes
No
Select...
Yes
No
Select...
Yes
No
Vehicle Driven by Which Driver / Miles to Work
Driver 1: Vehicle Number
Driver 1: Miles to Work
Driver 2: Vehicle Number
Driver 2: Miles to Work
Driver 3: Vehicle Number
Driver 3: Miles to Work
Final Questions
Currently Insured?
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Yes
No
Current Insurance Carrier?
How Long With Current Carrier?
Anti-Spam Question:
(Required)
Is fire hot or cold?
