Agent Info:
Name : Bradley K Johnson
License ID : 10093364
Phone : (701) 356-3265
Email : [email protected]
Address : Fargo ND 58104 US 58104

Auto

  • Applicant
  • Carrier
  • Losses
  • Drivers
  • Vehicles
  • Coverage
  • Finish

Applicant

Can you tell us about yourself?

First Name *
Last Name *
Date of Birth *
Marital Status

Where should we send your quote?

Email *
Phone *

Home Address

Address *
City *
State *
Zip Code *
Mailing Address
Address *
City *
State *
Zip Code *

What is your Occupation or Educational degree

(Discounts may apply)
Education Level
Industry /​ Occupation *
Specify (Industry/​Occupation) *
School Name *
School Address
Address *
City *
State *
Zip Code *
Company Name *
Company Address
Address *
City *
State *
Zip Code *

Please fill all the mandatory questions.

Carrier

Date of closing the Escrow
Please explain the reason not carrying an insurance

Please tell us about your current insurance

Current Auto Insurance Carrier *
Current Auto Insurance Expiration Date *
Current Premium
Current Home Insurance Carrier
Are you being cancelled or non-renewed?
What is the Reason?

Please fill all the mandatory questions.

Losses

Loss 1

Loss / Claim details
Please specify type of loss *
Date of loss *
Amount of Loss
Description of loss

Please fill all the mandatory questions.

Drivers

Driver 1

Can you tell us about the Driver?

Full Name *
Relationship to the applicant
Date of Birth *
Marital Status *

What does s/he do for a living?

(Discounts may apply)
Education Level
Industry /​ Occupation *
Specify (Industry/​Occupation) *
School Name *
School Address
Address *
City *
State *
Zip Code *
Company Name *
Company Address
Address *
City *
State *
Zip Code *

License Information

Driver's License Number *
License State
Age Licensed (Years)

Ticket 1

Ticket Information

Type of Ticket
Please specify Type of Ticket
Date of Ticket

Accident Information

Accident 1

Accident Information

Type of Accident
Please specify Type of Accident
Date of Accident

Please fill all the mandatory questions.

Vehicles

Vehicle 1

Vehicle Details

What is the VIN Number
Purchased Date
Year *
Make *
Model *
Body Style

Usage for the Vehicle

Vehicle Usage
Annual Mileage *
Mile to work
Odometer Reading *

Please fill all the mandatory questions.

Coverage

Bodily Injury *

(Per Person / Per Accident in $1000)

Property Damage

(Per $1000)

Uninsured /​ Underinsured Motorist
Uninsured Motorist Property Damage/Collision Deductible Coverage
Medical
Comprehensive Deductible *
Collision Deductible *
Rental Reimbursement

(Per day / Maximum 30 days)

Please fill all the mandatory questions.



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