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Auto Quote

Auto Quote

Tell us about yourself and your vehicle so we can find you the best insurance options. All of our partners are reputable auto insurance companies, so you can rely on the insurers you are approved for. We deliver the best rates available to you with no hassle.

Auto Quote

Insured Name:

Phone:

Email:

Insured DOB:

Insured Address

Secondary Driver Name:

Secondary Driver Gender:

Secondary Driver DOB:

Secondary Driver License State:

Secondary Driver Marital Status:

Secondary Driver Occupation:

Second Driver Relationship to Applicant:

Third Driver Name:

Third Driver Gender:

Third Driver DOB:

Third Driver License State:

Third Driver Marital Status:

Third Driver Occupation:

Third Driver Relationship to Applicant:

Fourth Driver Name:

Fourth Driver Gender:

Foutrh Driver DOB:

Fourth Driver License State:

Fourth Driver Occupation:

Fourth Driver Relationship to Applicant:

Do you presently have auto insurance?

Current Auto Insurances

Renewal Date:

Annual Premium:

Have you been canceled or non-renewed in the past 3 years?

Bodily Injury Liability:

50/100

100/300

250/500

Property Damage Liability:

$25,000

$50,000

$100,000

Medical Payments:

$1000

$2500

$5000

Uninsured Motorist Liability:

50/100

100/300

250/500

Uninsured Motorist Property

$1000

$2500

$5000

Under Insured Liability:

50/100

100/300

250/500

Comprehensive Deductible

No Coverage

$250

$500

$1000

Collision Deductible:

No Coverage

$250

$500

$1000

Rental Reimbursement:

Yes

No

Towing & Labor:

Yes

No

First Vehicle Year

First Vehicle Make & Model

First Vehicle Vin Number

First License State

First Vehicle Mileage

First Vehicle Number of Doors

Two Door

Four Door

Second Vehicle Year

Second Vehicle Make & Model

Second Vehicle Vin Number

Second License State

Second Vehicle Mileage

Second Vehicle Number of Doors

2 doors

4 doors

Third Vehicle Year:

Third Vehicle Make & Model

Third Vehicle Vin Number

Third License State

Third Vehicle Mileage

Third Vehicle Number of Doors

2 door

4 door

Fourth Vehicle Year:

Fourth Vehicle Make & Model

Fourth Vehicle Vin Number

Fourth License State

Fourth Vehicle Mileage

Fourth Vehicle Number of Doors

2 door

4 door

Opt-In

The premiums quoted are estimates based on information provided. The quotation does not constitute a contract, or provide overage for any loss or claim. Coverage only becomes active when bound by an agent with a signed application from the applicant and a down payment.

Thank you for submititng your auto, a agent will review your information and reach out to you as soon as possible.

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Home
About Us
Quotes
- Auto Quote
- Home Quote
Information
- Insurance Services
- Companies we represent
Contact

Contact info

203-693-2300
info@ctstatewideinsurance.com
554 Boston Post Road, Suite 15
Milford, CT 06460

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