Contacting Us Get A Quote Home
Return to Personal Insurance | Return to "Get a Quote" This form is for quoting Automobile/Motorcycle/ATV Insurance. Fill this form out as completely as possible. The more information we have the more accurate the quote will be. Completion of this form does not bind coverage. Items with an must be filled in. Name: Email Address: Telephone: Street Address: City/State/Zipcode: --Select-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zipcode: County: --Select One-- Geauga Trumbull Lake Ashtabula Cuyahoga Summit Other... Other County: Contact Via: Select One Email Telephone US Mail Best Time to Contact: Select One Early Morning Late Morning Noon Early Afternoon Late Afternoon Evening Basic Insurance Questions: Presently Insured: --Select One-- Yes No for Six Consecutive Months: --Select One-- Yes No Do you have any accidents/violations: --Select One-- Yes No Driver Information: Date of Birth (xx/xx/xx) Social Sec. Number Relationship to Insured Driver #1: --Select One-- Spouse Child Relative Other Driver #2: --Select One-- Spouse Child Relative Other Driver #3: --Select One-- Spouse Child Relative Other Driver #4: --Select One-- Spouse Child Relative Other Vehicle Information: Primary Driver # Vehicle ID # Coverage Usage -- Driver 1 Driver 2 Driver 3 Driver 4 --Select One-- Liability Full Coverage --Select One-- Pleasure Work < 3 miles Work 3-15 miles Work >15 miles -- Driver 1 Driver 2 Driver 3 Driver 4 --Select One-- Liability Full Coverage --Select One-- Pleasure Work < 3 miles Work 3-15 miles Work >15 miles -- Driver 1 Driver 2 Driver 3 Driver 4 --Select One-- Liability Full Coverage --Select One-- Pleasure Work < 3 miles Work 3-15 miles Work >15 miles -- Driver 1 Driver 2 Driver 3 Driver 4 --Select One-- Liability Full Coverage --Select One-- Pleasure Work < 3 miles Work 3-15 miles Work >15 miles -- Driver 1 Driver 2 Driver 3 Driver 4 --Select One-- Liability Full Coverage --Select One-- Pleasure Work < 3 miles Work 3-15 miles Work >15 miles Level of Protection: Bodily Injury: --Select One-- $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 $300,000 combined limit $500,000 combined limit Comprehensive Deductible: --Select One-- $0 $50 $100 $250 $500 $1,000 Property Damage: --Select One-- $10,000 $25,000 $50,000 $100,000 Medical Payment: --Select One-- $1,000 $2,000 $5,000 $10,000 Collision Deductible: --Select One-- $0 $250 $500 $1,000 Towing: --Select One-- Yes No Rental: --Select One-- None $15 per day $20 per day $30 per day Additional Comments or Explanations: Write as much as needed... How did you find us: --Select One-- Newspaper Phone Book Radio Referral Search Engine Television Web Site Personal Insurance Got A Question? Get A Quote Mail Payments to: The Frank Agency, Inc. P.O. Box 877 Middlefield, OH 44062-0877 Had An Accident: For an auto accident, please call the number on the back of your insurance card, then contact us with the details. For all other claims, please call us at 800-782-8328 so we can report the incident to your company. Need to Talk: 800-782-8328 Toll Free 440/632-5656 Personal Insurance | Commercial Insurance | Health Insurance | Financial Services | Investments | Get A Quote | Contacting Us The Frank Agency, Inc. • 15977 East High Street • Middlefield, Ohio 44062 • V: 440/632-5656 • F: 440/632-1859 • E: info@frankagency.com