AutoInsurance Quote
(Washington & Oregon residents only)

There are a variety of auto insurance coveragesbased on your specific needs, including difficult situations (accidents/tickets) to discounted rates for good drivers, and autos with certain safety and/orsecurity features.  Please fill out the preliminary form below tohelp in obtaining the appropriate policy for you.  There are norequired fields, and any information you give will be confidential (we do not provide information to third parties -- see our privacy policy). NOTE:  some companies use credit as a means for quoting and/orproviding a policy.  If you would like to fill out our longform, click here.

If you prefer not to complete this form, please send us an email at quotes@blaineinsurance.com, or you may obtain a quote by faxing your current auto insurance declaration pages to 360-738-0193.  As well, you can talk to us in person by calling 360-647-0090 or toll free at 800-676-0090.


 
Auto Insurance Quote Request
Name 
Address 
City 
State  Zip 
Social Security Number
Phone
E-mail (enter correctly or leave blank) 
Present auto insurance company
How long?
Date auto
insurance expires
Current
monthly payment
Length at present address
Time in current profession
Do you own a home? YesNo
Vehicle #
 Vehicle Identification
Number (VIN) if known		 Year Make
(i.e., Ford)		 Model & Class
(i.e., Windstar GL)
1
2
3
  Driver 1 Driver 2 Driver 3
Driver Name
Date of Birth
Sex
Marital Status
Occupation
Number of Tickets in Last 3 Years
Number of Accidents in Last 3 Years
At fault?YesNo
At fault?YesNo
At fault?YesNo
LIABILITYLIMIT FOR ALL VEHICLES
Bodily
Injury		 Property
Damage
Combined Single Limit (choose one)
$25,000/$50,000 $10,000
$60,000
$50,000/$100,000 $25,000
$100,000
$100,000/$300,000 $50,000
$300,000
$250,000/$500,000 $100,000
$500,000
$500,000/$1,000,000 $500,000
$1.000,000
Choose either Bodily Injury & Property Damage OR Combined Single Limit
Quote with Underinsured/Uninsured Mortorists (UIM)
Quote with Personal Injury Protection (PIP)
Checkhere for minimum limits only.
Vehicle #
 Deductible
Comprehensive		 Deductible
Collision
1
 $100 $250 $500 $250 $500 $1000
2
 $100 $250 $500 $250 $500 $1000
3
 $100 $250 $500 $250 $500 $1000
Vehicle #
 Tow Loss ofUse
(Rental Reimbursement)
1
 YesNo YesNo
2
 YesNo YesNo
3
 YesNo YesNo
Please include comments (info on tickets, accidents, coverage requests, or auto safety features).

Please note this is only a quote and does not bind coverage in any way.  Leased vehicles shall be quoted with bodily injury liability limits of $100,000/$300,000 unless requested otherwise.

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Thank you for your interest!  Email us at quotes@duanesammons.com or call 360-647-0090 or toll free at 800-676-0090 for further assistance or questions.
 

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