Auto Insurance
Online Quote Request

A service of Blake, Hall & Sprague Insurance
170 Ocean Street South Portland, ME  04116-2403 (207)799-5541

Please provide the information below to receive a
Auto Insurance Quotation.
This service is currently available only for residents of the State of Maine.

We will email your quote, usually within one business day.
Submit as many optional quote requests as you would like.

To ensure accuracy, and to reduce your entry time,
please have your current policy in front of you.

General Information

Name:

Address:

City, State, ZIP:

Phone #:

Home

Work

email address:

Current Coverage Information

Have you had continuous auto insurance for the past six months?

Yes

No

What company insures your auto(s) now?

When does your current policy expire?

Driver Information
(include all drivers in your household)

Gender and
Marital Status

Driving
Experience

Occupation

Driver Name

DOB

Driver 1

License # / State:

Social Sec. #:

Driver 2

License # / State:

Social Sec. #:

Driver 3

License # / State:

Social Sec. #:

Driver Discounts
Check the driver numbers assigned above for anyone who meets the following:

Is an Honor Roll / Dean's List student:

#1

#2

#3

Is away at school over 100 miles without a car:

#1

#2

#3

Graduated from a Driver Training program:

#1

#2

#3

Accidents and Violations
Please provide information about each driver's record over the last THREE YEARS. Provide details of each accident or violation in the free space below, including: when; where; how much was paid for the accident; and circumstances.

Tickets or
Convictions

Not-At-Fault
Accidents

At-Fault
Accidents

Driver #

1

Yes

No

Yes

No

Yes

No

2

Yes

No

Yes

No

Yes

No

3

Yes

No

Yes

No

Yes

No

Accident or Violation Details

Vehicle Information
List the vehicles that you would like quoted:
(submit additional forms for more than 4)

Vehicle # 1

Year

Make

Model, # doors, cylinders

Usual Driver:

Vehicle ID# (VIN)

Use:

Airbags:

Ownership:

Alarm:

Anti-Lock Brakes:

Vehicle # 2

Year

Make

Model, # doors, cylinders

Usual Driver:

Vehicle ID# (VIN)

Use:

Airbags:

Ownership:

Alarm:

Anti-Lock Brakes:

Vehicle # 3

Year

Make

Model, # doors, cylinders

Usual Driver:

Vehicle ID# (VIN)

Use:

Airbags:

Ownership:

Alarm:

Anti-Lock Brakes:

IMPORTANT!

Are any non-owned vehicles provided for the regular use of anyone in your household (e.g. a company car) ?
If "yes", please provide details in the "remarks" section at the end of this form.

Yes

No

Liability Coverage Information
This coverage is the same for ALL OF YOUR VEHICLES.

Bodily Injury and
Property Damage Liability

Uninsured / Underinsured
Motorist Coverage

Medical Payments (per person):

Physical Damage Coverage Information
This coverage can differ for each vehicle.

Vehicle
#

Comprehensive
Deductible

Collision
Deductible


Towing

Replacement Rental Coverage

1

2

3

You may be eligible for additional credits!
The following questions relate to credits offered by some companies.

Employer Name:
(include spouse's if applicable)

Do you own your home?

Yes

No

Are all residents of your home non-smokers?

Yes

No

Remarks

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© Blake, Hall & Sprague, Inc
170 Ocean Street 
South Portland, ME  04116-2403 
(207) 799-5541    (800) 373-5541
Maine Resident Producer Agency #AGR29506