Buying a new or used car involves more than picking out the perfect make and model. It also involves finding the right car insurance policy.Fill out the form below to receive a quote.   We offer a variety of coverages and companies to choose from, depending on your needs. Certain discounts may apply. Auto Quote Request Form Please fill out the preliminary form below and an agent will contact you. If you would prefer to speak directly to an agent, simply fill out the fields highlighted in blue. Personal Information First Name Last Name Address Address City State Zip Phone Number Email Operator Information What is the Full Name of the Vehicle Operator? What is the Operator's Date of Birth? ( --/--/--) What is the Operator's Gender? Male Female What is the Operator's Marital Status? Married Divorced Single Operator Discounts Is the Operator Eligible for a Good Student Discount? Yes No Has the Operator Completed a Driver Training Course? Yes No Has the Operator Completed a Defensive Driving Course? Yes No Driving Record Has the Operator Had a Moving Violation in the Last Three Years? Yes No Has the Operator Had an Accident in the Last Three Years? Yes No Prior Insurance Information Who Was the Last Insurance Carrier? Has the Operator Ever Had Insurance Canceled or Not Renewed? Yes No Vehicle Information What is the Vehicle Year? 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 or earlier What Is the Vehicle Make? (Chevrolet, BMW, Etc) What is the Vehicle Model? (Lumina, Z3, etc) Check if the Vehicle Has Any of the Following Safety Devices: Anti-Theft Air Bags ABS Passive Restraints Other Coverages How Much Bodily Injury Liability Coverage Are You Interested In? $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 How Much Property Damage Liability Coverage Are You Interested In? $50,000 $100,000 $250,000 $500,000 How Much Medical Liability Coverage Are You Interested In? $ 1,000 $ 2,000 $ 5,000 $10,000 How Much Uninsured/ Underinsured Motorist Liability Coverage Are You Interested In? $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 What Comprehensive Deductible Are You Interested In? $ 100 $ 250 $ 500 $1000 What Collision Deductible Are You Interested In? $ 100 $ 250 $ 500 $1000 Are You Interested in Towing/Labor Coverage? Yes No Are You Interested in Rental Reimbursement Coverage? Yes No Vehicle Use Is this Vehicle Used For Pleasure? Yes No Is This Vehicle Used For Work/School? Yes No If So, How Far One-Way? Miles How Many Miles Is This Vehicle Driven Every Year? , 000 Miles   Pacific Insurance Agency 8306 N. Wall St. Suite A Spokane, WA 99208 Phone: (509) 465-1133 (800) 600-4303 FAX: (509) 465-1134 info@pacific-insurance.com The Agency | Employee Benefits | Resources Home | Commercial | Life | Auto ©2000 Pacific Insurance Agency, Inc. All Rights Reserved.