Please complete the information requested below as accurately as possible, and upon your submission an Sterling Personal Insurance Division representative will contact you within 24 hours to provide your quote.

If you wish to speak to an Sterling representative directly, please call our Personal Insurance Division at (586) 323-5700. For the Lansing office call (517) 323-3737.

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Personal Information

Name:*

Employer/Occupation:

Email:*

Address:*

 

City:*

State:*

Zip Code:*

Phone:*

Date of Birth:

Any tickets or accidents in the past 5 years? - Select - Yes No

Current Auto Insurance

Present Insurer:

Annual Premium:

Bodily injury liability - Select - $20,000/40,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 $500,000/1,000,000

Property damage - Select - $10,000 $50,000 $100,000 $250,000 $500,000

Comprehensive Deductible - Select - No Coverage $50 $100 $200 $250 $500 $1000

Collision Deductible - Select - No Coverage $50 $100 $150 $200 $250 $500 $1000

Collision Form - Select - Broad Regular Limited

Health Insurance Carrier:

About Your Household

Spouse/Significant Other:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

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Dependents/Other Household Members:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

Has own insurance? - Select - Yes No

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Dependents/Other Household Members:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

Has own insurance? - Select - Yes No

Vehicle Information

Vehicle 1:
Year:*

Make:*

Model:*

VIN#:

Miles one way to work:*

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Vehicle 2:
Year:

Make:

Model:

VIN#:

Miles one way to work:

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Vehicle 3:
Year:

Make:

Model:

VIN#:

Miles one way to work:

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Remarks:

 

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