Personal Auto Quote Form

Thanks for your interest in an auto insurance quote from our agency through our website.

We ask these questions intentionally, in a certain order and for specific reasons. Each answer will give us necessary information so that we may propose our top options to you.

Questions will go from basic "personal" information, to vehicles, drivers, then coverages. If a question requires an answer but does not apply to you, please insert "N/A" or "NONE".

We will need to verify information and may have additional questions for you before a policy can be bound. There will be no coverage placed without speaking with one of our licensed agents.

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Do you currently have insurance? *

If no, when did you last have insurance? *

If yes, who is your current insurance provider? *

Current policy end date? *

Current Policy Number? *

Any claims in last 5 years? *

Yes
No

Marital Status *

Spouse First Name

Spouse Last Name

Do you Own or Rent your home? *

Own
Rent

Vehicle 1 Year Model *

Vehicle 1 Make *

Vehicle 1 Model *

Vehicle 1 VIN *

Vehicle 1 Estimated Annual Mileage *

Vehicle 1 Use *

Vehicle 1 Date of Purchase *

Vehicle 1 Loan/Lienholder *

How many vehicles on policy (including Vehicle 1) *

Additional Vehicle(s) Information *

Any vehicle used for Uber, Lyft, Shipt, GrubHub or any other hired delivery service> *

Driver 1 Name (First & Last) *

Driver 1 Date of Birth *

License (State, Number)

Driver 1 Driver's License (State & Number) *

Does this driver have any major violations or claims in the last 5 years? *

Yes
No

How many total drivers on the policy (including Driver 1)? *

Additional Driver(s) information *

Coverages needed on policy? *

Collision Deductible Amount *

Other Than Collision (Comprehensive) Deductible Amout *

How did you hear about us? *

Additional Comments

Submission Validation

Required

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.

Insurance Websites Designed and Hosted by Insurance Website Builder

716 W Gore Blvd
Lawton, OK 73501

Call: 580-353-0668
Text: 580-232-7475
Fax: 580-353-8007

Email: lawton@smithsonsinsurance.com