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Do you Currently Have Auto Insurance? *

Number of Vehicles to Insure *

Vehicle #1

Vehicle 1 VIN

Vehicle #2

Vehicle 2 VIN

Vehicle #3

Vehicle 3 VIN

Vehicles With Full Coverage *

Additional Vehicles - List Here

Comprehensive Deductible

Collision Deductible

Collision Type

Towing

Rental

Current Liability Coverage (Bodily Injury) *

Medical Insurance *

Total People in Household (incl. Kids) *

Total Licensed Drivers in Household *

Marital Status *

Residence Info *

First Name *

Last Name *

Date of Birth *

Driver 2 (Full Name)

Date of Birth

Driver 3 (Full Name)

Date of Birth

List any Additional Drivers and Date of Birth's

Any Tickets/Accidents in the last 3 yrs for any Driver? (list driver, date, and violation)

Member of any of these Groups?

Member of a Credit Union?

If Yes, Which Credit Union? (List Multiple)

Do you currently or are you interested in also bundling your Home/Renter policies? *

Do you currently or would you like to bundle an umbrella policy? *

Would you like to bundle a no exam life insurance policy? (In some cases the policies will be free due to multi policy discount) *

Are you willing to install a device in your car to track your driving to get a discount? (up to 30%) *

Street Address *

City *

ZIP / Postal Code *

How Many Years at Current Address? *

If less than 2 years at current address, list previous address:

Primary Phone Number *

E-Mail Address *

What lead you to our site? *

Any additional Info we should know?

Important Notice:

Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us. Per the terms of our online privacy policy we will not resell your information to any third-party.

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Schwab Insurance Agency, Inc
4794 Industrial Dr.
Millington, MI 48746
Phone: (989) 871-4505
Fax: (989) 871-5505
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