Phone * Address
* Desired Policy Effective Date
MM slash DD slash YYYY
Prior Insurance *
Please tell us if you currently have auto insurance.
Prior Insurance *
Please list prior insurance company and effective dates
If available, please upload a copy of your current declarations page.
List Drivers * List Vehicles * Collision Deductible *
Collision coverage pays to repair your car in the event you are responsible for the damage or involved in a hit and run. This is the amount you are responsible for paying before the insurance company pays.
Please Select $1,000 $500 $250 $100 No Coverage Other Than Collision Deductible *
Other Than Collision (comprehensive) coverage pays for losses to your car that are not due to a collision, such as theft, vandalism, glass breakage, hitting a deer, etc.
This is the amount you are responsible for paying before the insurance company pays.
Please Select $1,000 $500 $250 $100 No Coverage Rental Reimbursement *
Rental Reimbursement pays for you to rent a car if your car is off the road due to a covered loss.
Per day / Per occurrence.
Please Select $40 / $1,200 $50 / $1,500 $75 / $2,250 No Coverage Roadside Assistance *
Roadside Assistance will provide towing service as well as roadside services such as a jump start, fuel delivery, flat tire change and lockout assistance.
Bodily Injury and Property Damage *
Bodily injury pays in the event you injure others in an accident and also provides for a legal defense if you are sued. Property damage pays for the damage you've caused to someone else's property.
Please Select $15,000 / $30,000 / $15,000 $25,000 / $50,000 / $25,000 $50,000 / $100,000 / $50,000 $100,000 / $300,000 / $100,000 $250,000 / $500,000 / $100,000 $500,000 / $500,000 / $100,000 $100,000 Combined Limit $300,000 Combined Limit $500,000 Combined Limit Tort Option *
Full tort allows you to sue for monetary and non-monetary damages as a result of any accident.
Limited tort means that you cannot sue for non-monetary damages (pain and suffering) unless you were seriously injured.
Uninsured and Underinsured Motorist *
Uninsured motorist coverage protects you in in the event you are injured
by someone without any liability coverage. Underinsured motorist coverage protects you if they do not have sufficient coverage.
Please Select $15,000 / $30,000 $25,000 / $50,000 $50,000 / $100,000 $100,000 / $300,000 $250,000 / $500,000 $500,000 / $500,000 $100,000 $300,000 $500,000 Stacking Option *
Stacking your Uninsured and Underinsured Motorist coverages multiplies the coverage limit by the number of vehicles on the policy.
Medical Coverage *
This covers medical expenses you may need to treat injuries resulting from an accident involving a vehicle.
Please Select $5,000 (Required Minimum) $10,000 $25,000 $50,000 $100,000 $1,100,000 Wage Loss *
This coverage pays your lost wages in the event you are unable to work due to injuries sustained in an auto accident. Per month / Total
Please Select $1,000 / $5,000 $1,000 / $15,000 $1,500 / $15,000 $1,500 / $25,000 $2,500 / $50,000 No Coverage Accidental Death *
This pays in the event of a fatal accident.
Please Select $5,000 $10,000 $25,000 No Coverage Funeral Benefit *
This helps cover funeral costs in the event of death from an auto accident.
Please Select $1,500 $2,500 No Coverage Additional Comments * Ride-Sharing & Delivery *
Do you currently drive or intend to drive for Uber, Lyft, Grubhub, or other delivery services?
How do you intend to pay your auto insurance?
One Last Thing!
How did you hear about Frees Insurance?
Please Select Google Social Media Referred By Friend or Family Other Please Explain Client Name